Management of Acute Esophageal Variceal Hemorrhage

Abstract

Acute esophageal variceal hemorrhage (AEVH) is a devastating complication of portal hypertension. Evaluation of the natural history of AEVH showed that it is associated with a mortality rate of 40%, and a high incidence of early rebleeding of 30-50% among the survivors [1]. The factors responsible for AEVH are not well known. Portal pressure, variceal pressure, and the tension of the esophageal variceal wall have been demonstrated to be associated with AEVH. Hepatic venous pressure gradient (HVPG) > 12 mmHg is noted to be a requisite in patients with variceal rupture [2]. Poor hepatic reserve and the appearance numerous red color signs on the large varices are important factors predicting AEVH [3]. In Taiwan, for unknown reasons, gastroenterologists have noted that the incidence of AEVH is higher in the winter season.There are a handful of treatment modalities available for the management of AEVH. Vasoconstrictors and endoscopic therapy are the most frequently used tools to control AEVH. Appropriate use of these modalities should improve the survival of patients with AEVH. This article reviewed the relevant literature and summarized the limitations and advantages of the various treatment modalities used for AEVH; and to provide practical guidance for clinicians to manage this severe medical emergency.

Controlled trial of ligation plus vasoconstrictor versus proton pump inhibitor in the control of acute esophageal variceal bleeding

“…Subsequently, pantoprazole 40 mg tablet was administered orally for 14 days. Standard therapy, including blood and frozen plasma transfusion, fluid and electrolytes replacement, and prophylactic antibiotics (cefazolin 1 gm q6 h for 5 days) and lactulose were administered to patients in both groups as clinically indicated . All the patients signed an informed consent.…”

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

“…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.…”

“…This will control the bleeding in the majority of patients. However, in cases where the bleeding is not controlled by initial measures, emergency transjugular intrahepatic portosystemic shunt is the best alternative in those who can tolerate the procedure [20,21,23] . Only 3 of our patients had emergency surgery for refractory variceal bleeding.…”

“…Only 3 of our patients had emergency surgery for refractory variceal bleeding. Immediate liver transplantation may be considered if possible in appropriate candidates [21,23,25] . Repeated endoscopic management until complete obliteration is achieved is recommended for patients who responded to this procedure [20,21] .…”

Application of Endoscopy in Improving Survival of Cirrhotic Patients with Acute Variceal Hemorrhage

“…However, the time interval of band ligation remains an unsettled issue. Although some studies proposed an interval of 1 to 2 weeks [69, 70, 74], others advocated an interval of 1-2 months of band ligation for obliteration of EV [75, 76]. Yoshida et al found a short interval between sessions of EVL might even be detrimental by showing that the overall rates of variceal recurrence and additional treatment were both higher in patients with EVL at a biweekly interval than those with a bimonthly protocol [76].…”