Variceal bleeding

Typically presents with a painless, effortless, and recurrent hematemesis.

Treatment with vasoactive drugs, prophylactic antibiotics, and endoscopic techniques are standard treatments for acute esophageal variceal bleeding.

Initial management for a suspected variceal bleed is a hemodynamic assessment and support.

Vasoactive agents that decrease splanchnic blood flow, such as vasopressin or somatostatin analogues are initiated early as possible.

Acute Variceal Hemorrhage treatment includes the combination of a safe vasoconstrictor (terlipressin, somatostatin, or analogues such as octreotide or vapreotide, administered from the time of admission and maintained for 2 to 5 days, and endoscopic therapy preferably endoscopic variceal ligation, performed at diagnostic endoscopy <12 hours after admission), together with short-term antibiotic prophylaxis with ceftriaxone.


The only vasoconstrictor currently available in the United States is octreotide.

In acute variceal bleeding treament failure occurs in about a 10-15% of cases and repeat endoscopic treatments are required and transjugular intrahepatic portosystemic shunt may control such bleeding.

The somatostatin analogue octreotide is the most commonly used agent and a continuous infusion for up to five days is recommended to prevent early rebleeding.

In patients with high risk for variceal bleeding with cirrhosis and hepatic venous pressure gradient of 20 mm Hg or more early treatment with TIPS improved the prognosis compared to conventional medical therapy (Monescillo E).

The use of extended polytetrafluoroethylene covered stents is associated with reductions in the incidence of TIPS dysfunction and recurrence of complications related to portal hpertension (Bureau C).

In patients with cirrhosis hospitalized for acute variceal bleeding and at high risk for treatment failure, the early use of TIPS is associated with significant reductions in treatment failure and mortality (Garcia-Pagan JC).

Endoscopic banding superior to endoscopic sclerotherapy.

Restricting red blood cell transfusion to when the hemoglobin level drops below 7 g/dL decreases the risk of mortality, whereas excessive transfusion may increase portal pressure and the risk of re-bleeding from varices is increased.

Bacterial infections and pneumonia develop in as many as 50% of patients after an episode of variceal bleeding.

Prophylactic antibiotics reduce the risk of infection and mortality, and should be given to a patient with variceal bleeding.

Quinolone antibiotics and third generation cephalosporins are preferred antibiotic choices.

Upper gastrointestinal endoscopy is performed once the patient is hemodynamically stable and occurs typically after a few hours.

During endoscopy active or recent variceal bleeding band ligation can be performed

Recurrent bleeding within 24 hours despite two sessions of band ligation may occur in 10-20% of patients.

In patients with recurrent bleeding emergency TIPS should be performed.

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