Varices and variceal bleed resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Twinkle Singh, M.B.B.S. [2]

Overview

Variceal hemorrhage is one of the most common fatal complications of cirrhosis resulting from portal hypertension. Half of the patients with cirrhosis have gastroesophageal varices. Hepatic venous pressure gradient of >10 mmHg is the strongest predictor of their development. EGD is the gold standard investigation for their diagnosis. Vasoconstrictive pharmacologic therapy and endoscopic variceal ligation are the first line treatment in the management of acute variceal hemorrhage.

Approach to Varices in a Cirrhotic Patient

Patient diagnosed with cirrhosis

No active bleeding

Active bleeding

Screening EGD

See below

No varices

Esophageal varices

Gastric varices

Compensated cirrhosis

De-compensated cirrhosis

Small(<5mm)

Medium/Large(>5mm)

Cyanoacrylate or EVL

Repeat EGD in 3 years

Repeat EGD annually

High risk of hemorrhage†

Not at high risk of hemorrhage‡

High risk of hemorrhage†

Not at high risk of hemorrhage‡

Non selective beta blockers

Non selective beta blockers can be used (long tern benefits not established)

Non selective beta blockers (propanolol,nadolol) or EVL

Non selective beta blockers preferred (propanolol, nadolol), EVL in case of contraindication or intolerance to beta blockers

Algorithm as per practice guidelines approved by American Association for the Study of Liver Diseases (AASLD) and American College of Gastroenterology (ACG).

Management of Actively Bleeding Varices

Suspected acute variceal hemorrhage ❑ Patient with known cirrhosis and/ ❑ Coffee ground emesis

General measures: ❑Admit the patient to ICU ❑ Assess airway ❑ Obtain peripheral venous access ❑ Intravascular volume resuscitation ❑ Blood transfusion (to maintain a hemoglobin of 8mg/dl)

Prophylactic antibiotics ❑ Oral norfloxacin (400mg BID)OR ❑ IV ciprofloxacin ❑IV ceftriaxone (1g/day) in advanced cirrhosis

Pharmacologic therapy: ❑ Vasopressin (IV infusion 0.2 to 0.4 units/min up to 0.8 units/min)+ Nitroglycerine (IV 40 μg/min can be increased up to 400 μg/min) OR ❑ Terlipressin (IV 2 mg/4 hours titrated down to 1 mg/4 hours), not available in US, OR ❑ Somatostatin (250 μg IV bolus followed by 250 μg/hr continuous infusion) OR ❑ Octreotide (somatostatin analogue), IV bolus of 50μg followed by continuous infusion 50μg/hour

Endoscopic therapy ❑ Early EGD recommended for diagnosis and treatment (with in 12 hours of admission) ❑ Endoscopic variceal ligation (preferred) ❑ Sclerotherapy (if EVL is not feasible)

Algorithm as per practice guidelines approved by American Association for the Study of Liver Diseases (AASLD) and American College of Gastroenterology (ACG).