Management of Variceal Bleed

pathophysiology

• Results from portal hypertension with hepatic venous pressure gradient >10 mm Hg
• Bleeding risk increases at portal pressures >12 mm Hg
• Increased resistance diverts portal blood flow to systemic circulation
• Dilated intraesophageal/gastric veins form
• Rupture occurs when wall tension exceeds vessel strength

clinical presentation

• Hematemesis (bright red or coffee-ground)
• Melena or hematochezia
• Splenomegaly (common in portal hypertension)
• Pallor, fatigue, hypovolemic shock

acute stabilization

airway and access

• Maintain airway, support breathing, ensure circulation
• Intubate for severe encephalopathy or massive bleed
• Secure two large-bore intravenous cannulas
• Insert nasogastric tube to monitor bleeding, assess output, clear stomach

fluid and blood replacement

• Resuscitate with crystalloids (normal saline)
• Transfuse packed red blood cells
• Target hemoglobin 7-9 g/dL
• Avoid over-transfusion; prevents rebound portal pressure increase

coagulopathy correction

• Administer intravenous vitamin K
• Transfuse fresh frozen plasma, platelets, or cryoprecipitate (if fibrinogen <1 g/L)

pharmacologic therapy

vasoactive agents

• Initiate rapidly, preferably before endoscopy
• Octreotide (somatostatin analogue): Initial intravenous bolus 1 $\mu g/kg$, followed by continuous infusion 1.0-5.0 $\mu g/kg/hr$. Decreases splanchnic blood flow
• Vasopressin: Potent splanchnic vasoconstrictor. Initial bolus 0.33 units/kg, then continuous infusion. Higher adverse effect profile (ischemia, hypertension)
• Terlipressin: Prodrug of vasopressin, administered 8-20 $\mu g/kg$ every 4-8 hours

adjunctive medications

• Administer intravenous proton pump inhibitors (e.g., pantoprazole) to prevent stress erosions and reduce acid injury
• Initiate broad-spectrum antibiotics (e.g., third-generation cephalosporins for 7 days) to prevent secondary bacterial infections

endoscopic management

therapeutic modalities

• Perform within 12 hours of presentation after hemodynamic stabilization
• Endoscopic variceal ligation (EVL): Preferred method. Uses multiple band ligator to strangulate varix. Lower complication rate
• Endoscopic sclerotherapy (EST): Inject sclerosants (1% ethoxysclerol, ethanolamine) intra/paravariceal. Alternative for children <2 years where banding device is too large
• Gastric varices: Inject tissue adhesive glue (N-butyl-2-cyanoacrylate)

refractory bleeding management

mechanical tamponade

• Sengstaken-Blakemore or Minnesota tube
• Mechanical compression of varices
• Temporizing measure (<12 hours)
• Risk of aspiration, necrosis, perforation

interventional and surgical options

• Transjugular intrahepatic portosystemic shunt (TIPS): Interventional radiology procedure. Metallic stent connects portal and hepatic vein. Reduces portal pressure. Used as bridge to transplant
• Surgical shunts: Distal splenorenal shunt, meso-caval shunt, or Meso-Rex bypass. Indicated for preserved synthetic liver function
• Liver transplantation: Definitive treatment for underlying end-stage liver disease or fulminant failure