Variceal bleeding

From greek.doctor

Bleeding from oesophageal varices is a severe complication of portal hypertension. It’s a common complication of cirrhosis, affecting up to 60% of patients with decompensated cirrhosis.

1/3 of patients with cirrhosis develop variceal bleeding in the first 2 years. The mortality rate is very high, up to 40%.

Clinical features

Variceal bleeding presents as sudden severe upper GI bleeding in a patient with known liver disease or long-standing risk factors for liver disease.

Treatment

Variceal upper GI bleeding is severe and rarely stops spontaneously. They may also rebleed.

Pharmacological therapy of variceal bleeding includes vasoactive drugs, which either inhibit release of vasodilative hormones or induce vasoconstriction directly. In either case, the splanchnic blood flow is reduced, which decreases the bleeding. The first line is terlipressin, second line somatostatin or octreotide. All of these drugs decrease bleeding, but only terlipressin decreases mortality.

Antibiotic prophylaxis with ceftriaxone for 7 days is also indicated due to high risk of infections.

Balloon tamponade may be used to stop the bleeding temporarily. This is only a short-term solution as rebleeding often occurs once the balloon is deflated and removed.

Definite treatment of variceal bleeding is either band ligation or sclerotherapy. These should be combined with pharmacological therapy (terlipressin).

Band ligation is generally the first choice of the two. It involves endoscopically placing small elastic bands around varices. This is similar to the procedure used for haemorrhoids.

Sclerotherapy involves endoscopic injection of a sclerosing solution into the varices.

Primary prevention

All patients who receive the diagnosis of cirrhosis should undergo upper GI endoscopy to look for oesophageal varices.

  • No varices
    • -> repeat procedure in 2 years if cirrhosis is compensated
    • -> repeat procedure in 1 year if cirrhosis is decompensated
  • Grade I varices
    • -> repeat procedure in 1 year
  • Grade II or III varices
    • -> propranolol as prophylaxis
    • If intolerant to propranolol, prophylactic band ligation

Secondary prevention

After one episode of oesophageal bleeding, interventions to prevent rebleeding are indicated. These include both:

  • Pharmacological therapy with propranolol or carvedilol
  • Band ligation
    • Repeated every 1 – 4 weeks until varices are eradicated

If bleeding occurs despite the aforementioned measures, placement of a transjugular intrahepatic portosystemic shunt (TIPS) is indicated.