Variceal Bleeding - Management

Treatment involves several different components:

i) Hemodynamic Resuscitation with IVFs and blood products

• Clearly, these patients are often volume down and with significant blood loss, and require blood products in the form of PRBCs, platelets, FFP, and cryo.  Main caution is to avoid overhydrating and over-transfusing, due to concern of increasing portal pressure and thus worsening bleeding.  A good rule of thumb is to aim for a Hct of ~24 in these patients. 

ii)  Preventing Common Complications

• Aspiration – often need intubation for airway protection
• Sepsis – these pts are extremely prone to developing bacteremia, spontaneous bacterial peritonitis, UTIs, and PNA.  There is an established role for prophylactic antibiotics in cirrhotic bleeders, with evidence showing decreased infections, mortality, and possibly decreasing recurrent bleeding as well. Reasonable choices include a fluoroquinolone (Cipro IV) or Ceftriaxone x 7 days.   PLEASE DO NOT FORGET TO GIVE ANTIBIOTICS IN CIRRHOTIC BLEEDERS
• Hepatic encephalopathy – often need to aggressively treat with lactulose, etc
• Renal failure – commonly complicates variceal bleed, both due to ATN and Hepatorenal syndrome.
• Alcohol Withdrawal

iii)  Medical Management of the variceal bleeding

• Octreotide is drug of choice – somatostatin analog that inhibits splanchnic vasodilation, indirectly causing splanchnic vasoconstriction and decreased portal inflow.  Given as a 50 mcg bolus, then 50 mcg/hr x 3-5 days.  Despite its automatic use in variceal bleeders, it has not clearly been shown to improve mortality.
• PPI drip is often used as well, to increase gastric pH (acidic environment inhibits hemostasis and clot formation)

iv)  Technical Management of Bleeding

• Endoscopy with band ligation is typically the procedure of choice, although sclerotherapy is still an option.  Banding, however, fails to control bleeding in 10-20% of patients.
• If patient rebleeds, most GI specialists would try repeat EGD and banding.
• Blakemore tube is also an option for difficult to control bleeding – basically, place a tube down the esophagus into the stomach and inflate a balloon around it, causing tamponade of the bleeding varices.  Patients must be intubated prior to this.  Risks include esophageal necrosis and rupture which can be fatal.  Usually used as a temporizing measure until TIPS.

v)  TIPS – Transjugular Intrahepatic Portosystemic Shunt

• Involves creation of a low-resistance channel between the hepatic veins and intrahepatic portion of the portal vein, thereby decompressing the portal system.  Done by Interventional Radiology.
• Main indications are recurrent variceal bleeding despite adequate endoscopic treatment, or active bleeding refractory to medical and endoscopic treatment.  It also has an indication for refractory ascites despite high doses of diuretics.   There is also less robust data for other potential indications, including hepatorenal syndrome, hepatic hydrothorax, and portal hypertensive gastropathy, among other things.  Never use it as primary prophylaxis of varices that have never bled.
•  Main contraindications to keep in mind is presence of Hepatocellular Carcinoma – slamming a TIPS catheter through a tumor is a bad idea; also, CHF especially with pulmonary hypertension and right heart dysfunction, as TIPS will significantly increase blood flow and volume to the right heart.
• Besides technical complications, main downsides to TIPS are an increase in portosystemic encephalopathy (due to shunting of toxin-filled blood away from the liver, into systemic circulation).  Also, TIPS is associated with increased mortality when done in patients with high MELD >18-20 (MELD scores were originally used to predict mortality after TIPS).

(Chanu Rhee MD, 11/23/10)