Variceal bleeding

Abstract

Primary prophylaxis: Patients with cirrhosis who have esophageal varices but who have never had a bleeding episode may be treated medically or endoscopically. Without treatment, approximately 30% of cirrhotic patients with varices bleed and this risk is reduced by approximately 50% with therapy. Medical therapy includes nonselective beta blockers with or without nitrates. Compliance and side effects limit efficacy. Primary prophylaxis with endoscopic sclerotherapy is not warranted because of evidence suggesting that complications outweigh benefits. Studies of endoscopic therapy with ligation (endoscopic banding) demonstrate that in select patients (those with large varices), endoscopic banding may reduce the risk of first bleeding episode when compared with propranolol. Patients with large varices may benefit from a combination of banding with nonselective beta blockers. Secondary prophylaxis: After an initial variceal bleed, the risk of a second bleed is high and therapy is warranted to reduce the risk of rebleeding. The options are similar to those for primary prophylaxis, and in addition to medical and endoscopic therapy, transjugular intrahepatic portosystemic shunts (TIPS) and surgical shunts are therapeutic options. The combination of endoscopic therapy with medical therapy is the initial approach to prevent variceal rebleeding. Endoscopic banding is preferred to sclerotherapy because banding is associated with lower bleeding rates and fewer complications. TIPS is useful in cases refractory to endoscopic therapy or in uncontrolled variceal hemorrhage. Surgical shunts are typically reserved for patients in whom TIPS cannot be performed for technical reasons or for well-compensated cirrhotic patients. Acute variceal bleeding: Acute bleeding from esophageal varices requires an endoscopic evaluation and therapeutic intervention. Technically, endoscopic banding may not be possible because of limited visualization from bleeding and sclerotherapy is used because it is easier to perform in this setting. A continuous intravenous drip of octreotide should be initiated if variceal bleeding is suspected. If variceal bleeding cannot be controlled, then a Minnesota tube or Sengstaken-Blakemore tube should be placed by someone with experience. TIPS is effective rescue therapy for controlling acute variceal hemorrhage in circumstances when other methods fail.

Management of Variceal Hemorrhage

“…The non-selective β-blockers, including propranolol and nadolol, are the recommended agents for primary prophylaxis of variceal hemorrhage [8, 16]. It is believed that they can reduce portal pressure by reducing cardiac output as well as splanchnic arterial blood flow [4, 9, 17].…”

“…Thus, the selective β-blockers are considered ineffective in prevention of variceal hemorrhage if it doesn’t affect splanchnic circulation [8]. The therapy usually starts with a low dose and then increases to an optimal dose step by step [9, 16]. As discussed above, sequential measurements of HVPG are not widely used in assessing the therapeutic response of β-blockers, therefore, most clinicians empirically adjust the dosage via observing the reduction in heart rate.…”

“…As discussed above, sequential measurements of HVPG are not widely used in assessing the therapeutic response of β-blockers, therefore, most clinicians empirically adjust the dosage via observing the reduction in heart rate. The optimal dosage is generally considered to be able to reduce the resting heart rate by 25%, or to reduce the resting heart rate to 55 beats per minute [9, 16]. However, the reduction in heart rate does not virtually correlate with the decrease in portal pressure [9, 16].…”

“…Nadolol is a preferred agent with fewer adverse effects [8, 16]. Considering these drawbacks, patients with small varices or without varices do not need to take non-selective β-blockers for primary prophylaxis; only patients with medium or large varices take it as the current agent to prevent the first episode of hemorrhage.…”

“…Considering these drawbacks, patients with small varices or without varices do not need to take non-selective β-blockers for primary prophylaxis; only patients with medium or large varices take it as the current agent to prevent the first episode of hemorrhage. The nitrates, such as isosorbide mononitrate (ISMN), could further reduce portal pressure [9, 17], however, it is now no longer used in mono-therapy, it is recommended to be used with β-blockers when patients are not adequately sensitive to β-blockers [1, 8, 16]. Moreover, approximately 30% of patients with large varices have contraindication or intolerance to β-blockers [9, 17].…”