Management of bleeding gastro-oesophageal varices

Patients with bleeding gastro-oesophageal varices are usually managed in a high-dependency or intensive care unit with facilities for central venous pressure and arterial monitoring. Management includes endoscopic treatment, vasoactive drug therapy and antibiotic prophylaxis.

Patients should be resuscitated to restore and maintain haemodynamic stability. Blood transfusion may be required, but avoid overtransfusion because it can further increase portal pressure—for most patients, aim for a haemoglobin concentration of 70 to 80 g/L. Similarly, overcorrection of coagulopathy with large volumes of fresh frozen plasma can increase portal pressure and precipitate further bleeding (see Coagulopathy in patients with cirrhosis for information about bleeding risk).

An emergency endoscopy should be performed within 12 hours of presentation to confirm that varices are the source of the bleeding, since peptic ulcer disease is also common in cirrhosis (see Bleeding peptic ulcers). Bleeding oesophageal varices are treated with endoscopic band ligation (banding), while bleeding gastric varices are treated with local injection of cyanoacrylate.

In patients with portal hypertension and upper gastrointestinal bleeding, splanchnic blood flow and portal pressure can be reduced by terlipressin or octreotide. Treatment should be started as soon as possible after presentation. Use:

Terlipressin or octreotide is continued after endoscopy to prevent early rebleeding. A duration of 2 to 3 days may be used for less severe episodes—seek specialist advice. Beta blockers should be started as soon as vasoactive drugs are stopped (see Secondary prevention of bleeding gastro-oesophageal varices).

Patients receiving terlipressin do not need cardiac monitoring. However, terlipressin can cause systemic ischaemic adverse effects, and it should not be used in patients with diagnosed or suspected ischaemic heart disease.

If a proton pump inhibitor (PPI) was started before endoscopy, assess if there is an ongoing need for PPI therapy and, if there is not, the PPI should be stopped.

Patients with cirrhosis who present with upper gastrointestinal bleeding should receive prophylactic antibiotic therapy; see Prevention of infection in patients with cirrhosis and upper gastrointestinal bleeding.

If endoscopic treatment fails or is unavailable, and if bleeding persists despite the use of terlipressin or octreotide, blood loss can usually be controlled for 24 to 48 hours with balloon tamponade. When balloon tamponade tubes are used, inflate the gastric balloon only, check its position on X-ray, and apply traction for a maximum of 24 hours. Do not inflate the oesophageal balloon because it can cause severe oesophageal necrosis. When available, self-expanding oesophageal stents (eg Sx-Ella Danis stent) are an alternative to balloon tamponade and can remain in situ for 7 days.

In patients with ongoing bleeding, an emergency transjugular intrahepatic portosystemic shunt (TIPS) should be considered.

Pre-emptive placement of a TIPS within 72 hours of variceal haemorrhage can reduce mortality and may be considered in selected patients who are at high risk of rebleeding after endoscopic therapy. For further information about secondary prevention of bleeding gastro-oesophageal varices, see below.