Varices and variceal bleed resident survival guide: Difference between revisions

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__NOTOC__
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{{CMG}}; {{AE}} {{TS}}
{{CMG}}; {{AE}} {{TS}}, {{Rim}}


==Overview==
==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.<ref name="pmid17727436">{{cite journal| author=Garcia-Tsao G, Sanyal AJ, Grace ND, Carey WD, Practice Guidelines Committee of American Association for Study of Liver Diseases. Practice Parameters Committee of American College of Gastroenterology| title=Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. | journal=Am J Gastroenterol | year= 2007 | volume= 102 | issue= 9 | pages= 2086-102 | pmid=17727436 | doi=10.1111/j.1572-0241.2007.01481.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17727436  }} </ref>
Gastroesophageal varices are portosystemic collaterals resulting from portal hypertension which is a complication of [[cirrhosis]].  Gastroesophageal varices are prone to rupture leading to life threatening hemorrhage.<ref name="pmid17727436">{{cite journal| author=Garcia-Tsao G, Sanyal AJ, Grace ND, Carey WD, Practice Guidelines Committee of American Association for Study of Liver Diseases. Practice Parameters Committee of American College of Gastroenterology| title=Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. | journal=Am J Gastroenterol | year= 2007 | volume= 102 | issue= 9 | pages= 2086-102 | pmid=17727436 | doi=10.1111/j.1572-0241.2007.01481.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17727436 }} </ref>
 
==Causes==
 
===Life Threatening Causes===
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.  Variceal bleed is a life-threatening condition and must be treated as such irrespective of the causes.
 
===Common Causes===
* [[Cirrhosis]]
 
==Management==
===Non Bleeding Varices in Cirrhosis===
Shown below is an algorithm depicting the screening and prophylaxis management of non bleeding varices in cirrhosis based on the practice guidelines approved by American Association for the Study of Liver Diseases (AASLD) and American College of Gastroenterology (ACG).<ref name="pmid17727436">{{cite journal| author=Garcia-Tsao G, Sanyal AJ, Grace ND, Carey WD, Practice Guidelines Committee of American Association for Study of Liver Diseases. Practice Parameters Committee of American College of Gastroenterology| title=Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. | journal=Am J Gastroenterol | year= 2007 | volume= 102 | issue= 9 | pages= 2086-102 | pmid=17727436 | doi=10.1111/j.1572-0241.2007.01481.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17727436  }} </ref>


==Screening and Management of Non Bleeding Varices in Cirrhosis==
{{familytree/start}}
{{familytree/start}}
{{familytree | | | | | | | | | | | B01 | | | | | | | | | | | | | | |B01=❑ '''Diagnosis of cirrhosis''' <br>❑ '''No evidence of variceal bleed'''}}
{{familytree | | | | | | | B01 | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left">❑ '''Diagnosis of cirrhosis''' <br>❑ '''No evidence of variceal bleed''' </div>}}
{{familytree | | | | | | | | | | | |!| | | | | | | | | | | | | | | }}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | C01 | | | | | | | | | | | | | | C01='''Screen for varices:'''<br> Order an EGD}}
{{familytree | | | | | | | C01 | | | | | | | | | | | | | | C01=<div style="float: left; text-align: left">'''Screen for varices:'''<br> Order an Esophagogastroduodenoscopy (EGD)</div>}}
{{familytree | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|-|-|.| | |}}
{{familytree | | | |,|-|-|-|^|-|-|-|.| | |}}
{{familytree | | | D01 | | | | | | D02 | | | | | | D03 | | |D01=No varices|D02=Esophageal varices|D03=Gastric varices}}
{{familytree | | | D01 | | | | | | D02 | |D01='''No varices'''|D02='''Presence of varices'''}}
{{familytree | | | |!| | | |,|-|-|-|^|-|-|-|.| | | |!| | | }}
{{familytree | | | |!| | | |,|-|-|-|^|-|-|-|.| | }}
{{familytree | | | E01 | | E03 | | | | | | E04 | | E05 | | |E01='''Follow up with EGD:'''<br> ❑ Every 3 years<br> ❑ At the time of any hepatic decompensation, and annually thereafter|E03='''Small (<5mm)'''|E04='''Medium/Large''' <br>'''(>5mm)'''|E05=❑ Cyanoacrylate or EVL}}
{{familytree | | | E01 | | E03 | | | | | | E04 |E01=<div style="float: left; text-align: left">'''Follow up with EGD:'''<br> ❑ Every 3 years<br> ❑ At the time of any hepatic decompensation, and annually thereafter</div>|E03='''Small (<5mm)'''|E04='''Medium/Large''' <br>'''(>5mm)'''}}
{{familytree | | | | | | | |!| | | | | | | |!| | }}
{{familytree | | | | | | | |!| | | | | | | |!| | }}
{{familytree | | | | | | | E05 | | | | | | E06 | E05= ❑ '''Assess risk of hemorrhage'''| E06=❑ '''Assess risk of hemorrhage'''}}
{{familytree | | | | | | | E05 | | | | | | E06 | E05= ❑ '''Assess risk of hemorrhage'''| E06=❑ '''Assess risk of hemorrhage'''}}
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{{familytree | | | | | F03 | | F04 | | F05 | | F06 | F03='''High'''†|F04='''Low'''‡|F05='''High'''†|F06='''Low'''‡}}
{{familytree | | | | | F03 | | F04 | | F05 | | F06 | F03='''High'''†|F04='''Low'''‡|F05='''High'''†|F06='''Low'''‡}}
{{familytree | | | | | |!| | | |!| | | |!| | | |!| | }}
{{familytree | | | | | |!| | | |!| | | |!| | | |!| | }}
{{familytree | | | | | G01 | | G02 | | G03 | | G04 | G01=❑ Non selective beta blockers '''should''' be used|G02=❑ Non selective beta blockers '''may''' be used, '''OR''' <br> ❑ EGD every 2 years if beta blockers are '''not''' used|G03=❑ Non selective beta blockers, '''OR'''<br> ❑  EVL|G04= '''First line:''' Non selective beta blockers <br>❑ '''Second line:''' EVL}}
{{familytree | | | | | G01 | | G02 | | G03 | | G04 | G01=<div style="float: left; text-align: left">[[Propranolol]] (starting dose: 20mg), orally, twice per day, '''OR'''<br>❑ [[Nadolol]] (starting dose: 40mg), orally, once per day</div>|G02=<div style="float: left; text-align: left">[[Propranolol]] (starting dose: 20mg), orally, twice per day, '''OR'''<br>❑ [[Nadolol]] (starting dose: 40mg), orally, once per day,<ref name="pmid20200386">{{cite journal| author=Garcia-Tsao G, Bosch J| title=Management of varices and variceal hemorrhage in cirrhosis. | journal=N Engl J Med | year= 2010 | volume= 362 | issue= 9 | pages= 823-32 | pmid=20200386 | doi=10.1056/NEJMra0901512 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20200386  }} </ref> '''OR''' <br> ❑ EGD every 2 years if beta blockers are not used</div>|G03=<div style="float: left; text-align: left">❑ [[Propranolol]] (starting dose: 20mg), orally, twice per day, '''OR'''<br>❑ [[Nadolol]] (starting dose: 40mg), orally, once per day,<ref name="pmid20200386">{{cite journal| author=Garcia-Tsao G, Bosch J| title=Management of varices and variceal hemorrhage in cirrhosis. | journal=N Engl J Med | year= 2010 | volume= 362 | issue= 9 | pages= 823-32 | pmid=20200386 | doi=10.1056/NEJMra0901512 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20200386  }} </ref> '''OR''' <br> ❑  Endoscopic variceal ligation</div>|G04= <div style="float: left; text-align: left">'''First line:''' <br> ❑ [[Propranolol]] (starting dose: 20mg), orally, twice per day, '''OR'''<br>❑ [[Nadolol]] (starting dose: 40mg), orally, once per day<ref name="pmid20200386">{{cite journal| author=Garcia-Tsao G, Bosch J| title=Management of varices and variceal hemorrhage in cirrhosis. | journal=N Engl J Med | year= 2010 | volume= 362 | issue= 9 | pages= 823-32 | pmid=20200386 | doi=10.1056/NEJMra0901512 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20200386  }} </ref><br> <br>'''Second line:''' Endoscopic variceal ligation</div>}}
{{familytree | | | | | | | | | | | | | |`|-|v|-|'| | }}
{{familytree | | | | | | | | | | | | | |`|-|v|-|'| | }}
{{familytree | | | | | | | | | | | | | | | H01 | | | H01= '''If a patient is treated with EVL:'''<br> ❑ Repeat EVL every 1-2 weeks until obliteration <br> ❑ Perform a first surveillance EGD 1-3 months after obliteration <br> ❑ Repeat EVL every 6-12 months to check for variceal recurrence}}
{{familytree | | | | | | | | | | | | | | | H01 | | | H01= <div style="float: left; text-align: left">'''If a patient is treated with endoscopic variceal ligation:'''<br> ❑ Repeat endoscopic variceal ligation every 1-2 weeks until obliteration <br> ❑ Perform a first surveillance EGD 1-3 months after obliteration <br> ❑ Repeat endoscopic variceal ligation every 6-12 months to check for variceal recurrence</div>}}
{{familytree/end}}
{{familytree/end}}
Algorithm as per practice guidelines approved by American Association for the Study of Liver Diseases (AASLD) and American College of Gastroenterology (ACG).<ref name="pmid17879356">{{cite journal| author=Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W, Practice Guidelines Committee of the American Association for the Study of Liver Diseases. Practice Parameters Committee of the American College of Gastroenterology| title=Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. | journal=Hepatology | year= 2007 | volume= 46 | issue= 3 | pages= 922-38 | pmid=17879356 | doi=10.1002/hep.21907| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17879356}}</ref><ref name="pmid24350068">{{cite journal| author=Karadsheh Z, Allison H| title=Primary Prevention of Variceal Bleeding: Pharmacological Therapy Versus Endoscopic Banding. | journal=N Am J Med Sci | year= 2013 | volume= 5 | issue= 10 | pages= 573-579 | pmid=24350068 | doi=10.4103/1947-2714.120791 | pmc=PMC3842697 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24350068  }} </ref>


† Varices at high risk of bleeding:
† Varices at high risk of bleeding:
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* No red wale marks on varices.
* No red wale marks on varices.


==Management of Actively Bleeding Varices==
===Actively Bleeding Varices===
Shoen below is an algorithm depicting the management of actively bleeding varices based on the  practice guidelines approved by American Association for the Study of Liver Diseases (AASLD) and American College of Gastroenterology (ACG).<ref name="pmid17727436">{{cite journal| author=Garcia-Tsao G, Sanyal AJ, Grace ND, Carey WD, Practice Guidelines Committee of American Association for Study of Liver Diseases. Practice Parameters Committee of American College of Gastroenterology| title=Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. | journal=Am J Gastroenterol | year= 2007 | volume= 102 | issue= 9 | pages= 2086-102 | pmid=17727436 | doi=10.1111/j.1572-0241.2007.01481.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17727436  }} </ref>
 
{{familytree/start}}
{{familytree/start}}
{{familytree | | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | |A01=<div style="float: left; text-align: left; line-height: 150% ">'''Suspected acute variceal hemorrhage'''
{{familytree | | | | | A01 | |A01=<div style="float: left; text-align: left; height: 5em; width: 45em; padding:1em;">'''Suspected acute variceal hemorrhage'''
----
----
❑ Patient with known cirrhosis <br> ❑ Coffee ground emesis <br>
❑ Patient with known [[cirrhosis]] <br> ❑ Coffee ground emesis <br>
</div>  }}
</div>  }}
{{familytree | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | |!| | }}
{{familytree | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | B01 | |B01=<div style="float: left; text-align: left; height: 12em; width: 45em; padding:1em;">
{{familytree | | | | | | | | | | | | | | | | B01 | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; line-height: 150% ">
'''General measures:'''
'''General measures:'''
------
------
❑Admit the patient to ICU<br>
❑ Admit the patient to ICU<br>
❑ Assess airway<br>
❑ Assess airway<br>
❑ Obtain peripheral venous access<br>
❑ Obtain peripheral venous access<br>
Intravascular volume resuscitation<br>
Blood volume resuscitation (maintain a hemoglobin of 8mg/dl)<br>
❑ Blood transfusion (to maintain a hemoglobin of 8mg/dl)</div> }}
❑ Elective or emergent tracheal intubation prior to endoscopy ( mainly in case of concomitant hepatic encephalopathy)</div> }}
{{familytree | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | |!| | }}
{{familytree | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | C01 | |C01=<div style="float: left; text-align: left; height: 8em; width: 45em; padding:1em;">'''Short term prophylactic antibiotics (7 days)'''
{{familytree | | | | | | | | | | | | | | | | C01 | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; line-height: 150% ">'''Prophylactic antibiotics'''
------
------
❑ Oral [[norfloxacin]] (400mg BID)OR  <br> ❑ IV [[ciprofloxacin]] <br>
❑ Oral [[norfloxacin]] (400mg twice daily), OR  <br> ❑ IV [[ciprofloxacin]] (impossible oral administration)<br>
❑IV ceftriaxone (1g/day) in advanced cirrhosis </div>}}
❑ IV ceftriaxone (1g/day) in advanced cirrhosis and in a setting with high prevalence of [[quinolone]] resistance</div>}}
{{familytree | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | |!| | }}
{{familytree | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | D01 | |D01=<div style="text-align: left; height: 14em; width: 45em; padding:1em;">'''Initiate pharmacological therapy when variceal bleed is suspected, even before confirming the diagnosis by EGD:'''
{{familytree | | | | | | | | | | | | | | | | D01 | | | | | | | | | | | | | | | | | | | |D01=<div style="float: left; text-align: left; line-height: 150% ">'''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<br>
[[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) adjusted to maintain a systolic blood pressure
❑ Terlipressin (IV 2 mg/4 hours titrated down to 1 mg/4 hours), not available in US, OR<br>  
90 mmHg, OR<br>
❑ Somatostatin (250 μg IV bolus followed by 250 μg/hr continuous infusion) OR<br>
[[Terlipressin]] (IV 2 mg every 4 hours titrated down to 1 mg every 4 hours)- not available in US- OR<br>
❑ Octreotide (somatostatin analogue), IV bolus of 50μg followed by continuous infusion 50μg/hour </div>}}
[[Somatostatin]] (250 μg IV bolus followed by 250 μg/hr continuous infusion) OR<br>
 
[[Octreotide]] (somatostatin analog), IV bolus of 50μg followed by continuous infusion 50μg/hour
{{familytree | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | E01 | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; line-height: 150% ">'''Endoscopic therapy'''
----
----
Early EGD recommended for diagnosis and treatment (with in 12 hours of admission)<br>
'''Continue pharmacological therapy 3-5 days after the diagnosis is confirmed''' </div>}}
❑ Endoscopic variceal ligation (preferred)<br>
{{familytree | | | | | |!| | }}
❑ Sclerotherapy (if EVL is not feasible)
{{familytree | | | | | E01 | E01=<div style="float: left; text-align: left; height: 2em; width: 45em; padding:1em;">'''Perform EGD:'''
</div>}}
❑ Confirm the diagnosis of variceal bleed (within 12 hours of admission) '''ASAP'''</div>}}
{{familytree | | | |,|-|^|-|.| | }}
{{familytree | | | E02 | | E03 | |E02= <div style="float: left; text-align: left; height: 3em; width: 15em; padding:1em;">'''Esophageal varices or gastric varices in the lesser curvature'''</div>| E03=<div style="float: left; text-align: left; height: 3em; width: 15em; padding:1em;">'''Gastric varices in the fundus'''</div>}}
{{familytree | | | |!| | | |!| | }}
{{familytree | | | E04 | | E05 | E04=  <div style="float: left; text-align: left; height: 7em; width: 15em; padding:1em;">''' Perform endoscopic therapy:'''<br>❑ Endoscopic variceal ligation (preferred)<br>❑ Sclerotherapy (if endoscopic variceal ligation is not feasible)</div>
| E05= <div style="float: left; text-align: left; height: 7em; width: 15em; padding:1em;">''' Perform endoscopic therapy:'''<br>❑ Endoscopic variceal obturation with tissue adhesive such as N-butyl-cyanoacrylate, isobutyl-2-cyanoacrylate, or thrombin</div>}}
{{familytree | | | |!| | | |!| | }}
{{familytree | | | E06 | | E07 |E06= <div style="float: left; text-align: left; height: 5em; width: 15em; padding:1em;">'''Failure to control OR recurrence of variceal bleed despite pharmacological and endoscopic therapy?'''</div>| E07=<div style="float: left; text-align: left; height: 5em; width: 15em; padding:1em;">'''Failure to control OR recurrence of variceal bleed despite pharmacological and endoscopic therapy?'''</div>}}
{{familytree | |,|-|^|.| |,|^|-|.| }}
{{familytree | G01 | | G02 | | G03 | G01='''Yes''' <br> <div style="float: left; text-align: left; height: 3em; width: 15em; padding:1em;"> ❑ TIPS, OR <br> ❑ Shunt surgery* </div>| G02= '''No'''<br> <div style="float: left; text-align: left; height: 3em; width: 45em; padding:1em;">'''Management following recovery of the patient:'''<br>❑ Secondary prophylaxis before discharge (non selective beta blocker + endoscopic variceal ligation) </div>| G03= '''Yes''' <br> <div style="float: left; text-align: left; height: 3em; width: 15em; padding:1em;"> ❑ TIPS</div>}}
{{familytree | |!| | | |!| | | |!| }}
{{familytree | G01 | | |!| | | |!| G01= <div style="height: 1em; width: 15em; padding:1em;">No secondary prophylaxis</div>}}
{{familytree | |`|-|-|-|+|-|-|-|'| }}
{{familytree | | | | | H01 | | | | H01= <div style="float: left; text-align: left; height: 1em; width: 45em; padding:1em;">❑ Refer [[transplant]] candidates to a transplant center</div>}}
{{familytree/end}}
{{familytree/end}}
Algorithm as per practice guidelines approved by American Association for the Study of Liver Diseases (AASLD) and American College of Gastroenterology (ACG).<ref name="pmid17879356">{{cite journal| author=Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W, Practice Guidelines Committee of the American Association for the Study of Liver Diseases. Practice Parameters Committee of the American College of Gastroenterology| title=Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. | journal=Hepatology | year= 2007 | volume= 46 | issue= 3 | pages= 922-38 | pmid=17879356 | doi=10.1002/hep.21907| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17879356}}</ref><ref name="pmid24350068">{{cite journal| author=Karadsheh Z, Allison H| title=Primary Prevention of Variceal Bleeding: Pharmacological Therapy Versus Endoscopic Banding. | journal=N Am J Med Sci | year= 2013 | volume= 5 | issue= 10 | pages= 573-579 | pmid=24350068 | doi=10.4103/1947-2714.120791 | pmc=PMC3842697 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24350068  }} </ref>
 
* Balloon tamponade should be used as a temporizing measure (maximum 24 hours) in patients with uncontrollable bleeding for whom a more definitive therapy is planned.


==Do's==
==Do's==
* [[Varices]] are only classified as small or large (>5mm) on EGD.
* Use either [[propranolol]] or [[nadolol]] when non selective beta blockers are indicated.
* In patients with small, non bleeding varices, who are not on [[beta blockers]], EGD is recommended to be repeated in 2 years.  In decompensated [[cirrhosis]], EGD should be done annually.
* If a patient is placed on [[beta blocker]], its dose should be adjusted to the maximum tolerated dose.
* For secondary prophylaxis of variceal bleed, beta blockers plus endoscopic therapy should be used.
* When endoscopic variceal ligation ([[EVL]]) is done, repeat EVL every 1 to 2 weeks until complete obliteration of varices.  Follow up with EGD after 1 to 3 months and every 6 to 12 months thereafter to screen for varices recurrence.
* If a patient is placed on beta blocker, its dose should be adjusted to maximum tolerated dose.
* Vasoconstrictive pharmacotherapy should be initiated as soon as variceal bleeding is suspected and should be continued for 3 to 5 days after the diagnosis of bleeding varices is established.
* If [[EVL]] is done, it should be repeated every 1 to 2 weeks, until varices are completely obliterated.  Follow up EGD is done after 1 to 3 months and after that every 6-12 months to look for any recurrence.
* Prophylactic antibiotics in patients with actively bleeding varices should be given only for a short term period (maximum 7 days).
* Vasoconstrictive pharmacotherapy ([[somatostatin]], [[octreotide]], [[vasopressin]]) should be started as soon as bleeding is suspected from varices and should be continued for 3-5 days after the diagnosis.
* [[TIPS]] is recommended in patients in whom bleeding is not controlled with combined endoscopic and pharmcological therapy.
* [[Balloon tamponade]] is a temporary measure (for 24 hours) to control variceal bleed used in patients for whom more definitive therapy is being planned.


==Dont's==
==Dont's==
* In patients with small varices, who are on beta blockers, follow up EGD is not recommended.
* In patients with small varices, who are on beta blockers, follow up with EGD is not recommended.
* Beta blockers are not recommended to prevent variceal development in cirrhotic patients with no varices.  
* Beta blockers are not recommended to prevent variceal development in cirrhotic patients with no varices.  
* [[Nitrates]], [[sclerotherapy]] and shunt therapy should not be used to prevent first variceal bleed.
* [[Nitrates]], [[sclerotherapy]] and shunt therapy should not be used to prevent first variceal bleed.
* Don't use beta blockers in acute bleed because it will cause reflex tachycardia that might worsen bleeding.
* Consider transfusion of [[FFP]] and [[platelet]]s in patients with significant coagulopathy and/or [[thrombocytopenia]].
* Don't provide excessive resuscitation with saline solution in variceal bleed.<ref name="pmid17727436">{{cite journal| author=Garcia-Tsao G, Sanyal AJ, Grace ND, Carey WD, Practice Guidelines Committee of American Association for Study of Liver Diseases. Practice Parameters Committee of American College of Gastroenterology| title=Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. | journal=Am J Gastroenterol | year= 2007 | volume= 102 | issue= 9 | pages= 2086-102 | pmid=17727436 | doi=10.1111/j.1572-0241.2007.01481.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17727436  }} </ref><ref name="pmid24350068">{{cite journal| author=Karadsheh Z, Allison H| title=Primary Prevention of Variceal Bleeding: Pharmacological Therapy Versus Endoscopic Banding. | journal=N Am J Med Sci | year= 2013 | volume= 5 | issue= 10 | pages= 573-579 | pmid=24350068 | doi=10.4103/1947-2714.120791 | pmc=PMC3842697 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24350068  }} </ref>


==References==
==References==
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{{Reflist|2}}

Latest revision as of 00:19, 13 March 2014

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Twinkle Singh, M.B.B.S. [2], Rim Halaby, M.D. [3]

Overview

Gastroesophageal varices are portosystemic collaterals resulting from portal hypertension which is a complication of cirrhosis. Gastroesophageal varices are prone to rupture leading to life threatening hemorrhage.[1]

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Variceal bleed is a life-threatening condition and must be treated as such irrespective of the causes.

Common Causes

Management

Non Bleeding Varices in Cirrhosis

Shown below is an algorithm depicting the screening and prophylaxis management of non bleeding varices in cirrhosis based on the practice guidelines approved by American Association for the Study of Liver Diseases (AASLD) and American College of Gastroenterology (ACG).[1]

 
 
 
 
 
 
Diagnosis of cirrhosis
No evidence of variceal bleed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Screen for varices:
❑ Order an Esophagogastroduodenoscopy (EGD)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No varices
 
 
 
 
 
Presence of varices
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Follow up with EGD:
❑ Every 3 years
❑ At the time of any hepatic decompensation, and annually thereafter
 
Small (<5mm)
 
 
 
 
 
Medium/Large
(>5mm)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assess risk of hemorrhage
 
 
 
 
 
Assess risk of hemorrhage
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
High
 
Low
 
High
 
Low
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Propranolol (starting dose: 20mg), orally, twice per day, OR
Nadolol (starting dose: 40mg), orally, once per day
 
Propranolol (starting dose: 20mg), orally, twice per day, OR
Nadolol (starting dose: 40mg), orally, once per day,[2] OR
❑ EGD every 2 years if beta blockers are not used
 
Propranolol (starting dose: 20mg), orally, twice per day, OR
Nadolol (starting dose: 40mg), orally, once per day,[2] OR
❑ Endoscopic variceal ligation
 
First line:
Propranolol (starting dose: 20mg), orally, twice per day, OR
Nadolol (starting dose: 40mg), orally, once per day[2]

Second line: Endoscopic variceal ligation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If a patient is treated with endoscopic variceal ligation:
❑ Repeat endoscopic variceal ligation every 1-2 weeks until obliteration
❑ Perform a first surveillance EGD 1-3 months after obliteration
❑ Repeat endoscopic variceal ligation every 6-12 months to check for variceal recurrence
 
 

† Varices at high risk of bleeding:

  • Cirrhosis with Child-Pugh class B or C severity.
  • Presence of red wale marks on varices visualized on endoscopy.

‡ Varices not at high risk of bleeding:

  • Cirrhosis with Child-Pugh class A severity.
  • No red wale marks on varices.

Actively Bleeding Varices

Shoen below is an algorithm depicting the management of actively bleeding varices based on the practice guidelines approved by American Association for the Study of Liver Diseases (AASLD) and American College of Gastroenterology (ACG).[1]

 
 
 
 
Suspected acute variceal hemorrhage

❑ Patient with known cirrhosis
❑ Coffee ground emesis

 
 
 
 
 
 
 
 
 
 
 
 
 
 

General measures:


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

❑ Elective or emergent tracheal intubation prior to endoscopy ( mainly in case of concomitant hepatic encephalopathy)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Short term prophylactic antibiotics (7 days)

❑ Oral norfloxacin (400mg twice daily), OR
❑ IV ciprofloxacin (impossible oral administration)

❑ IV ceftriaxone (1g/day) in advanced cirrhosis and in a setting with high prevalence of quinolone resistance
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initiate pharmacological therapy when variceal bleed is suspected, even before confirming the diagnosis by EGD:

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) adjusted to maintain a systolic blood pressure 90 mmHg, OR
Terlipressin (IV 2 mg every 4 hours titrated down to 1 mg every 4 hours)- not available in US- OR
Somatostatin (250 μg IV bolus followed by 250 μg/hr continuous infusion) OR
Octreotide (somatostatin analog), IV bolus of 50μg followed by continuous infusion 50μg/hour


Continue pharmacological therapy 3-5 days after the diagnosis is confirmed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform EGD: ❑ Confirm the diagnosis of variceal bleed (within 12 hours of admission) ASAP
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Esophageal varices or gastric varices in the lesser curvature
 
Gastric varices in the fundus
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform endoscopic therapy:
❑ Endoscopic variceal ligation (preferred)
❑ Sclerotherapy (if endoscopic variceal ligation is not feasible)
 
Perform endoscopic therapy:
❑ Endoscopic variceal obturation with tissue adhesive such as N-butyl-cyanoacrylate, isobutyl-2-cyanoacrylate, or thrombin
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Failure to control OR recurrence of variceal bleed despite pharmacological and endoscopic therapy?
 
Failure to control OR recurrence of variceal bleed despite pharmacological and endoscopic therapy?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
❑ TIPS, OR
❑ Shunt surgery*
 
No
Management following recovery of the patient:
❑ Secondary prophylaxis before discharge (non selective beta blocker + endoscopic variceal ligation)
 
Yes
❑ TIPS
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No secondary prophylaxis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Refer transplant candidates to a transplant center
 
 
 
  • Balloon tamponade should be used as a temporizing measure (maximum 24 hours) in patients with uncontrollable bleeding for whom a more definitive therapy is planned.

Do's

  • Use either propranolol or nadolol when non selective beta blockers are indicated.
  • If a patient is placed on beta blocker, its dose should be adjusted to the maximum tolerated dose.
  • When endoscopic variceal ligation (EVL) is done, repeat EVL every 1 to 2 weeks until complete obliteration of varices. Follow up with EGD after 1 to 3 months and every 6 to 12 months thereafter to screen for varices recurrence.
  • Vasoconstrictive pharmacotherapy should be initiated as soon as variceal bleeding is suspected and should be continued for 3 to 5 days after the diagnosis of bleeding varices is established.

Dont's

  • In patients with small varices, who are on beta blockers, follow up with EGD is not recommended.
  • Beta blockers are not recommended to prevent variceal development in cirrhotic patients with no varices.
  • Nitrates, sclerotherapy and shunt therapy should not be used to prevent first variceal bleed.
  • Don't use beta blockers in acute bleed because it will cause reflex tachycardia that might worsen bleeding.
  • Consider transfusion of FFP and platelets in patients with significant coagulopathy and/or thrombocytopenia.
  • Don't provide excessive resuscitation with saline solution in variceal bleed.[1][3]

References

  1. 1.0 1.1 1.2 1.3 Garcia-Tsao G, Sanyal AJ, Grace ND, Carey WD, Practice Guidelines Committee of American Association for Study of Liver Diseases. Practice Parameters Committee of American College of Gastroenterology (2007). "Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis". Am J Gastroenterol. 102 (9): 2086–102. doi:10.1111/j.1572-0241.2007.01481.x. PMID 17727436.
  2. 2.0 2.1 2.2 Garcia-Tsao G, Bosch J (2010). "Management of varices and variceal hemorrhage in cirrhosis". N Engl J Med. 362 (9): 823–32. doi:10.1056/NEJMra0901512. PMID 20200386.
  3. Karadsheh Z, Allison H (2013). "Primary Prevention of Variceal Bleeding: Pharmacological Therapy Versus Endoscopic Banding". N Am J Med Sci. 5 (10): 573–579. doi:10.4103/1947-2714.120791. PMC 3842697. PMID 24350068.