Variceal Bleeding

Methods to achieve hemostasis in patients with acute variceal hemorrhage - UpToDate

Overview of the management of patients with variceal bleeding - UpToDate

Approach to acute upper gastrointestinal bleeding in adults - UpToDate

## Primary prevention

• Nonselective beta blocker

  • Nadolol > propanolol

  • Carvedilol as alternative

  • Target HR 55-60, SBP > 90

  • Contraindications:

    • SBP (increases mortality)

    • Standard beta blocker contraindication

• Treat underlying medication condition

Treatment of Variceal bleeding

Acute Treatment

• ABCs

• Octreotide

  • 50 mcg IV bolus then 50 mcg/h IV infusion for 3-5 days

• Blood products as needed

  • Hgb > 70 unless severe hemorrhage or cardiovascular disease then 90-100

  • Platelets > 50,000

  • INR < 2.0

• Antibiotics

  • CTX 1 g IV x 7 days or cipro 500 mg PO q12 to complete 7 day course

  • Reduces incidence of SBP

• Endoscopy

  • <24h for acute UGIB

  • <12h for suspected variceal bleed

  • After resuscitation and more stable

• +/- NG tube

• +/- Sengstaken-Blakemore ("Blakemore") tube with 500cc in stomach balloon

Other considerations:

• IV PPI, bolus and infusion vs intermittent dosing

• Prokinetic

  • Erythromycin 250 mc IV 30-90 minutes before endoscopy

  • This is equivalent to NG lavage. Risk of QTc

• TXA has no role

Subsequent Measures

• Maintain NPO for 48-72 hours

• Abdo ultrasound Doppler to exclude portal vein thrombosis

• TIPS if refractory to medication and endoscopy, cannot do with PVT

• Monitor for:

  • SBP and other infections

  • Hepatic encephalopathy

  • Renal failure

Risk Scores

• Rockall score can be calculated after endoscopy

• Glasgow-Blatchford score does not require endoscopy

Secondary prevention

• NSBB as above

• Endoscopic variceal ligation (i.e. banding)