Diagnosis and management of acute variceal bleeding: Asian Pacific Association for Study of the Liver recommendations

Abstract

Background Acute variceal bleeding (AVB) is a medical emergency and associated with a mortality of 20% at 6 weeks. Significant advances have occurred in the recent past and hence there is a need to update the existing consensus guidelines. There is also a need to include the literature from the Eastern and Asian countries where majority of patients with portal hypertension (PHT) live. MethodsThe expert working party, predominantly from the Asia-Pacific region, reviewed the existing literature and deliberated to develop consensus guidelines. The working party adopted the Oxford system for developing an evidence-based approach. Only those statements that were unanimously approved by the experts were accepted. Results AVB is defined as a bleed in a known or suspected case of PHT, with the presence of hematemesis within 24 h of presentation, and/or ongoing melena, with last melanic stool within last 24 h. The time frame for the 123Hepatol Int (2011( ) 5:607-624 DOI 10.1007 AVB episode is 48 h. AVB is further classified as active or inactive at the time of endoscopy. Combination therapy with vasoactive drugs (\30 min of hospitalization) and endoscopic variceal ligation (door to scope time \6 h) is accepted as first-line therapy. Rebleeding (48 h of T 0 ) is further sub-classified as very early rebleeding (48 to 120 h from T 0 ), early rebleeding (6 to 42 days from T 0 ) and late rebleeding (after 42 days from T 0 ) to maintain uniformity in clinical trials. Emphasis should be to evaluate the role of adjusted blood requirement index (ABRI), assessment of associated comorbid conditions and poor predictors of nonresponse to combination therapy, and proposed APASL (Asian Pacific Association for Study of the Liver) Severity Score in assessing these patients. Role of hepatic venous pressure gradient in AVB is considered useful. Antibiotic (cephalosporins) prophylaxis is recommended and search for acute ischemic hepatic injury should be done. New guidelines have been developed for management of variceal bleed in patients with non-cirrhotic PHT and variceal bleed in pediatric patients. Conclusion Management of acute variceal bleeding in Asia-Pacific region needs special attention for uniformity of treatment and future clinical trials.

Management of Acute Variceal Bleeding

“…However, in contrast to patients with nonvariceal bleeding, too much transfusion or administration of fluids in patients with variceal bleeding can aggravate the bleeding resulting from increased portal venous pressure due to increased intravascular volume, and complications such as pulmonary edema and ascites may occur after hemostasis has been achieved; thus, close attention is required. It is recommended that hemoglobin levels should be maintained at 8 to 10 g/dL,10 although it is better to maintain it at 8 g/dL 11. When the level of consciousness declines, or in case of massive hemorrhaging, the systolic pressure should be maintained at >90 to 100 mm Hg, heart rate <100/min, and central venous pressure from 1 to 5 mm Hg 12.…”

Variceal hemorrhage: Saudi tertiary center experience of clinical presentations, complications and mortality

“…The main factor that predicts the severity of variceal bleeding is intravariceal pressure, and the level of bleeding could vary from moderate to life-threatening massive hemorrhage with shock [20,21] . Ascites has been reported as a predictor of the severity of AVB [22] . The fact that the bleeding was more severe in our patients with ascites could be due to an elevated portal vein pressure as a result of increased intra-abdominal pressure.…”

“…The initial management of AVB includes standard resuscitation measures in addition to the use of intravenous vasoconstrictors, such as Octreotide, followed by endoscopic therapy [20][21][22][23][24] . This will control the bleeding in the majority of patients.…”

The Management of Bleeding from Anorectal Varices

“…Vasoactive drugs aim to decrease splanchnic blood flow and portal pressure and are efficacious in the management of bleeding oesophageal varices [38]. In addition, empiric administration of antibiotics is considered standard of care in all cirrhotic patients presenting with GI bleeding [39][40][41] and significantly reduces the incidence of infection, resulting in decreased risk of rebleeding [42], all-cause mortality [43] and hospital length of stay. Both vasoactive therapy and antibiotics have an excellent safety profile, and their efficacy in anorectal variceal bleeding is inferred from their successful use in the management of esophageal varices.…”