Treatment specific to suspected Variceal Bleeding
Each episode of active variceal haemorrhage is associated with 30 percent mortality (UTD). Variceal bleeding stops spontaneously in over 50 percent of patients, but the mortality rate approaches 70 to 80 percent in those with continued bleeding.
Specific to variceal haemorrhage resuscitation is the need to avoid over-transfusion in the initial management of these patients as well as ensuring rapid consideration and correction of any coagulopathies.
Medical therapy aims at reducing the portal venous pressures and so reducing bleeding.
Early Vasoactive therapy should be commenced as promptly as possible on presentation of the patient who has known or suspected varices and should not be held pending confirmation of the diagnosis. Vasoactive medications have been shown to significantly decrease mortality and improve haemostasis in patients with acute variceal bleeding. (There is also some evidence to indicate their efficacy in non-variceal bleeding.)
Terlipressin 2 mg IV every four hours initially and then once haemorrhage is controlled, can be titrated down to 1 mg IV every four hours; or
Octreotide 50mcg Bolus followed by 50mcg/hr infusion for 5 days; or
Somatostatin 250mcg IV Bolus followed by 250mcg/hr infusion.
Antibiotics are indicated in variceal bleeding eg Ceftriaxone 1g IV (this decreases mortality in patients by reducing infections during ICU admissions)
Endoscopy is first line in variceal disease for diagnosis and intervention with potential banding or injection and decreases the risk of rebleeding to approximately 30 percent
Surgical intervention has little role in the management of varices and patients who do not respond to endoscopic therapies are best treated by Transjugular Intrahepatic Portosystemic Shunt (TIPSS).
Specifically, if the location of the varices is known;
Acute bleeding is typically managed with endoscopic variceal ligation within 12 hours (occasionally endoscopic sclerotherapy is used).
If the bleeding cannot be controlled endoscopically, transjugular intrahepatic portosystemic shunt (TIPS) placement or surgical shunting should be considered.
Treatment is with tissue adhesives (cyanoacrylate injection) where available
If cyanoacrylate injection is not an option, TIPS placement is typically used.
Bleeding ectopic varices may be managed with TIPS placement or surgery.
A guide to intubating the patient with a massive variceal bleed can be found here.
After intubation, Balloon tamponade is an option of last resort to temporarily stop bleeding from oesophageal or gastric varices while definitive treatment is being arranged, but it is associated with serious complications including oesophageal rupture – so always remember to confirm placement of the gastric balloon before you fully inflate it. Confirmation of placement is by listening over the stomach and lungs injecting air into the stomach port, and then inflating 50 mls of air or saline and doing X-ray top confirm in the stomach.
There are 3 types of tubes used for balloon tamponade. This video (EMRAP) provides an excellent overview.
1. Sengstaken-Blakemore tube - 3 ports (2 for filling the balloons with air, and 1 for gastric suction)
- 250cc gastric balloon, an oesophageal balloon, and a single gastric suction port
2. Minnesota tube – 4 ports (just a modified Sengstaken-Blakemore tube)
- Also has an oesophageal suction port above the oesophageal balloon
3. Linton-Nachlas tube – 1 port
- Which has a single, but larger 600cc, gastric balloon
An excellent blog entry on EMCrit here describes placement and has a downloadable pdf of a quick guide .
Remember that Balloon tamponade should only be considered as an interim and dire measure pending endoscopy or where endoscopy has failed and the patient is awaiting TIPS. More information on how to attempt balloon tamponade can be found here.
Long term, the administration of a nonselective beta blocker such as propranolol can also decrease the risk of rebleeding in variceal bleeders.