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 (Child A)

De-compensated cirrhosis (Child B/C)

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).

† 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).

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.