Varices and variceal bleed resident survival guide: Difference between revisions

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{{familytree | | | | | | | | | | | B01 | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left">❑ '''Diagnosis of cirrhosis''' <br>❑ '''No evidence of variceal bleed''' </div>}}
{{familytree | | | | | | | | | | | B01 | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left">❑ '''Diagnosis of cirrhosis''' <br>❑ '''No evidence of variceal bleed''' </div>}}
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{{familytree | | | | | | | | | | | |!| | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | C01 | | | | | | | | | | | | | | C01=<div style="float: left; text-align: left">'''Screen for varices:'''<br> Order an EGD</div>}}
{{familytree | | | | | | | | | | | C01 | | | | | | | | | | | | | | C01=<div style="float: left; text-align: left">'''Screen for varices:'''<br> Order an EGD</div>}}
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{{familytree | | | D01 | | | | | | D02 | | | | | | D03 | | |D01=No varices|D02=Esophageal varices|D03=Gastric varices}}
{{familytree | | | D01 | | | | | | D02 | | | | | | D03 | | |D01='''No varices'''|D02='''Esophageal varices'''|D03='''Gastric varices'''}}
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{{familytree | | | E01 | | E03 | | | | | | E04 | | E05 | | |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)'''|E05=❑ Cyanoacrylate or EVL}}
{{familytree | | | E01 | | E03 | | | | | | E04 | | E05 | | |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)'''|E05=❑ Cyanoacrylate or EVL}}

Revision as of 20:02, 30 December 2013

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.[1]

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).[1]


† 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
❑ 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).[2][3]

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.

References

  1. 1.0 1.1 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. 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 (2007). "Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis". Hepatology. 46 (3): 922–38. doi:10.1002/hep.21907. PMID 17879356.
  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.