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.

Screening and Management of Non Bleeding Varices in Cirrhosis

❑ Diagnosis of cirrhosis ❑ No evidence of variceal bleed

Screen for varices: ❑ Order an EGD

No varices

Esophageal varices

Gastric varices

Follow up with EGD: ❑ Every 3 years ❑ At the time of any hepatic decompensation, and annually thereafter

Small (<5mm)

Medium/Large (>5mm)

❑ Cyanoacrylate or EVL

❑ Assess risk of hemorrhage

❑ Assess risk of hemorrhage

High†

Low‡

High†

Low‡

❑ Non selective beta blockers should be used

❑ Non selective beta blockers may be used, OR ❑ EGD every 2 years if beta blockers are not used

❑ Non selective beta blockers, OR ❑ EVL

❑ First line: Non selective beta blockers ❑ Second line: EVL

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

The algorithm is based on the practice guidelines approved by American Association for the Study of Liver Diseases (AASLD) and American College of Gastroenterology (ACG).

† 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.

Management of Actively Bleeding Varices

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 BID), 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 every4 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 ❑ 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 Perform endoscopic therapy: ❑ Endoscopic variceal ligation (preferred) ❑ Sclerotherapy (if EVL is not feasible)

Failure to control OR recurrence of variceal bleed despite pharmacological and endoscopic therapy?

Yes ❑ TIPS, OR ❑ Shunt surgery ❑ 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 G02= No

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The algorithm is based on the practice guidelines approved by American Association for the Study of Liver Diseases (AASLD) and American College of Gastroenterology (ACG).

Do's

• Varices are only classified as small or large (>5mm) on EGD.
• 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.
• For secondary prophylaxis of variceal bleed, beta blockers plus endoscopic therapy should be used.
• If a patient is placed on beta blocker, its dose should be adjusted to maximum tolerated dose.
• 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

• In patients with small varices, who are on beta blockers, follow up 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.
• Avoid vigorous resuscitation with saline solution in variceal bleed.