Optimizing General Management of Acute Variceal Bleeding in Cirrhosis

Abstract

As soon as acute gastrointestinal bleeding is confirmed in patients with portal hypertension, treatment with vasoactive drugs and prophylactic antibiotics should be instituted. Once hemodynamic stability has been achieved, emergency endoscopy should be performed and endoscopic therapy (preferably with legation) should be carrier out when variceal bleeding is disclosed.

Survival of patients with cirrhosis and acute peptic ulcer bleeding compared with variceal bleeding using current first‐line therapies

“…The rates of further bleeding observed In both groups were similar to those previously reported for each of these hemorrhagic sources . Such a further bleeding rate was significantly higher in patients with AVB than in those with PUB.…”

“…All these factors may help to explain why, as suggested by our results, the risk of mortality in patients with cirrhosis and UGIB is similar whatever the source of bleeding, whether from esophageal varices or a peptic ulcer. This reinforces the assertion that the level of care and general management of patients with cirrhosis with UGIB should be the same in those with PUB as in those with AVB, requiring close monitoring and measures to prevent or treat complications, which may influence the final outcome …”

Over‐the‐scope clip for acute esophageal variceal bleeding

“…EBL is the endoscopic treatment of choice; however, esophageal mucosal fibrosis secondary to prior banding may arise leading either to a collapse of the bleeding varix or wall disruption, causing EBL failure. Alternative treatments such as endoscopic sclerotherapy can be considered; however, they have been reported to be less effective, with serious adverse events, and may be associated with a sustained elevation of HVPG …”

“…Alternative treatments such as endoscopic sclerotherapy can be considered; however, they have been reported to be less effective, with serious adverse events, and may be associated with a sustained elevation of HVPG. [3][4][5]14 Other less common techniques have been evaluated. Interestingly, endoscopic clipping for the management of AVH was initially reported by Miyoshi et al 15 in 1992.…”

“…However, esophageal bleeding control associated with portal hypertension (PHT) might be difficult using EBL due to either collapse of the bleeding varix or scarring the mucosa due to fibrosis secondary to long‐term treatment of EBL. Endoscopic sclerotherapy can be a less effective alternative when EBL is not feasible, and serious events such as sclerosant‐induced esophageal ulcerations may arise as a common complication, especially with collapsed varices . Finally, if bleeding control is not achieved, Sengstaken‐Blakemore tube or self‐expandable metal stent are considered as a temporary “bridge” until definitive treatment is instituted …”