Management of Acute Variceal Bleeding

* Gastroesophageal variceal bleeding accounts for 10-30% of upper gastrointestinal haemorrhage and is a major cause of death in patients with cirrhosis.
* The prevalence of oesophageal varices in patients with cirrhosis varies from 24-81%.
* At the time of diagnosis of cirrhosis, oesophageal varices are present in about 60% of decompensated and 30% of compensated patients.
* Despite the high occurrence of varices in cirrhotic patients, only 30% of patients with varices will experience variceal haemorrhage.
* The risk of bleeding appears to be greatest within the first year after diagnosis.
* Mortality of the first bleeding episode is high and ranges between 30% and 50% within 6 weeks; mortality from uncontrolled bleeding in the first instance is between 5-8%.
* Risk factors for the 1st episode of variceal bleeding in cirrhotic patients include - the severity of the liver dysfunction,
- the size of the varices (large greater than small), and
- the presence of endoscopic red wale signs.
- the hepatic venous pressure gradient (HVPG).
* Gastric varices account for approximately 20-30% of cases of variceal bleeding. The prevalence of gastric varices in patients with portal hypertension varies from 6-78% and approximately 25% of gastric varices bleed during lifetime.


General management of bleeding
Patients are usually managed in a high-dependency or intensive therapy unit with facilities for central venous pressure and arterial monitoring.
Therapy is aimed at - correcting hypovolumic shock and resuscitation
- achieving haemostasis at the bleeding site.

This include ABC & resuscitation, initially with plasma expanders and subsequently with blood. If coagulation is defective, replace coagulation factors with fresh frozen plasma. Platelet transfusions may also be required for thrombocytopenia.


Local Haemostasis
An emergency endoscopy should be performed to confirm that varices are the source of bleeding, since peptic ulcer disease is also common in cirrhosis. If possible, endoscopic treatment of varices should be undertaken by endoscopic variceal ligation (banding). Where banding is not possible, sclerotherapy may be useful, adverse events such as oesophageal ulceration and stricture were significantly more severe with sclerotherapy. The most commonly used sclerosants are sodium tetradecyl sulphate (thrombovar) and ethanolamine oleate.


Pharmacotherapy
Octreotide: Decrease portal pressure, 50 micrograms IV, immediately, then 25 to 50 micrograms per hour by IV infusion for 5 days.
While control of initial bleeding has been demonstrated with octreotide, no effect on mortality has been shown. Its transient effect is due to tachyphylaxis.
Terlipressin: 2 mg IV, 6-hourly for 2 to 3 days. It reduces splanchnic blood flow and portal pressure. A meta-analysis demonstrated that terlipressin was associated with a 34% relative risk reduction in mortality compared to placebo.
If endoscopic treatment fails/unavailable and bleeding persists despite octreotide or terlipressin, blood loss can usually be controlled with a Sengstaken-Blakemore–type tube for 24 hours. Balloon tamponade is known to have a high re-bleeding rate when the balloon is decompressed and is associated with serious complications such as ulceration, perforation and aspiration pneumonia. Thus, this should only be considered if facilities for endoscopy are not available prior to transfer to a tertiary centre or as a temporary ‘bridge’ for a maximum of 24 hours until definitive treatment can be instituted.

Antibiotics in Acute Variceal Bleeding
Bacterial infections are seen in about 20% of cirrhotics presenting with upper gastrointestinal bleeding within 48 hours. The incidence of sepsis increases to almost 66% at two weeks. Development of bacterial infection is associated with high mortality and variceal re-bleeding. Antibiotic prophylaxis has been shown to reduce the rate of infection, spontaneous bacterial peritonitis and rebleeding. In addition, antibiotic prophylaxis was clearly proven in a meta-analysis to significantly increase the survival rate. Short-term antibiotic prophylaxis for 7 days should be considered the standard of care in cirrhotic patients with upper gastrointestinal bleeding, irrespective of the type of haemorrhage (variceal or nonvariceal) or the presence or absence of ascites. As to the choice of antibiotic, either third generation cephalosporins given intravenously or oral quinolones (norfloxacin/ciprofloxacin) are generally recommended.

Continued bleeding
Continued bleeding is associated with a high mortality. A second course of endoscopic treatment may be undertaken with continued use of a Sengstaken-Blakemore–type tube for up to 24 hours. Adjunctive infusion of octreotide can be given. An emergency transjugular intrahepatic portosystemic shunt (TIPS) or an emergency portosystemic shunt may be considered, depending on available local expertise.
Transjugular intrahepatic portosystemic shunts (TIPS) is effective in the treatment of acute variceal bleeding with a success rate of over 90% in arresting haemorrhage. The main limiting factors to the use of TIPS are the high morbidity and mortality: the 30-day mortality approaches 100% in patients with advanced liver disease, ongoing sepsis and multi-organ failure. Therefore, the most widely accepted indication for TIPS is as a rescue therapy for uncontrolled variceal bleeding after combined pharmacological and endoscopic therapy.

Surgical Therapy
Surgical options include oesophageal transection with or without devascularisation, portosystemic shunts and liver transplantation. Regardless of the choice of the surgical technique, morbidity and mortality are high: the 30-day mortality associated with emergency surgical procedures is nearly 80%. Similar to TIPS, the role of surgical therapy in the management of acute variceal bleed has been relegated to salvage haemostatic therapy. Liver transplantation is probably only appropriate for liver transplant candidates who bleed while on the waiting list.

Prevention of rebleeding
In patients with cirrhosis who have bled from oesophageal varices, the risk of rebleeding within 12 months is about 60%. Measures to reduce this risk include regular endoscopic banding until varices have largely disappeared. In the longer term, varices recur and may need further banding. In a meta-analysis of clinical trials, therapy with propranolol has been shown to reduce recurrent variceal bleeding and improve survival. In those who rebleed despite the above therapy, TIPS, portosystemic shunt or transplantation should be considered.