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Gastroesophageal Varices and Hemorrhage

H. Anh Nguyen

Background

  • Varices form due to portosystemic collaterals in the setting of portal HTN
  • Gastroesophageal varices are present in approximately 50% of patients with cirrhosis and their presence correlates with severity of liver disease
  • The risk of mortality with esophageal variceal hemorrhage (EVH) can be up to 15-20%
  • Recurrence occurs in over 60% of patients within 1-2 years of the index event
  • The most important predictor of hemorrhage is the size of the varices. Other predictors include decompensated cirrhosis (Child B/C) and endoscopic presence of red wale marks or red spots

Variceal Screening

  • Not all pts with cirrhosis require screening. Can be omitted without clinically significant portal hypertension (e.g. low liver stiffness (on elastography) and platelets >150) or if pt already on non-selective beta blocker (NSBB) with HR 55-60

  • Compensated cirrhosis without varices: EGD q3yr, unless active liver injury (obesity, EtOH use, ongoing viral infxn), then q2yr

  • Compensated cirrhosis with small varices: EGD q2yr unless active liver injury, then q1yr

  • Decompensated cirrhosis with no or small nonbleeding varices: EGD q1yr, and at initial time of decompensation

Management (Non-Bleeding Varices)

  • Primary ppx with either NSBB (preferred) or endoscopic band ligation (EBL)

    • Nadolol (given nightly as portal pressures are highest at night) or propranolol (BID)
    • Carvedilol has greater portal pressures and may be preferred if tolerated (goal 6.25mg BID)
    • For 2 º ppx, initiate ~72hr after acute bleed has resolved and octreotide discontinued
    • Discontinue if: hypotension (sBP <90), AKI, SBP or hyponatremia with refractory ascites

  • Secondary ppx with both NSBB and EBL.

  • NSBB are associated with reduced mortality, while EBL is not

Management (Bleeding Varices)

  • Place two large-bore IVs (18G or larger), resuscitate with blood products and albumin. Activate massive transfusion protocol if needed.

  • Consider intubation if need for emergent EGD, change in mental status, ongoing hematemesis, concern of ability to protect airway

  • Start octreotide 50 mcg IV bolus followed by continuous infusion of 50 mcg/h, to be continued for at least 2 days should EVH be confirmed on endoscopy

  • Ceftriaxone 1g IV q24h for SBP prophylaxis (reduced mortality), then transition to PO ciprofloxacin for total 7-day course

  • Consult GI for upper endoscopy. Endoscopic therapies performed include variceal band ligation and sclerotherapy.

  • Consider balloon tamponade with Blakemore as temporizing measure before definitive management. Patient must be intubated before placement, and preferably GI should be made aware prior to placement.

  • No role for the correction of INR, even in the presence of bleeding as excessive blood products and FFP can increase portal pressures and cause worsening bleeding

    • Vitamin K can be given w/ ↑ INR, though is unlikely to help in the acute setting
    • Check TEG and fibrinogen and transfuse based on results
    • AASLD does not recommend specific platelet targets during variceal hemorrhage
    • Administer blood products in balanced ratio to avoid transfusion related coagulopathy (VUMC MTP is 6:4:1 of RBC:FFP:PLT)