Gastroesophageal Varices and Hemorrhage¶
Patricia Checinski
Background¶
-
Varices form due to portosystemic collaterals in the setting of portal HTN
-
The risk of mortality with each episode of esophageal variceal hemorrhage (EVH) is 15-25%
-
Recurrence occurs in 60% of patients within 1-2 years of the index event
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)