Bleeding oesophageal varices (management)

Consult expert advice and local guidelines.

Initial resuscitation of the patient:

• IV access and cross-match blood
• test for hypoglycaemia
• CVP line
• consider Swan-Ganz catheter in those with ascites or associated medical problem
• transfuse colloid, then cross matched whole blood

After initial resucitation then early endoscopy, optimally within four hours, enables accurate identification of the bleeding site, which may not always be from varices.

Measures are employed to halt the bleeding:

• if endoscopic expertise is available then:
  • if oesophageal varices, then injection sclerotherapy or band ligation
  • if gastric varices, then alternatives include injection sclerotherapy endoscopic injection of N-butyl-2-cyanoacrylate
    
    
• other measures include:
  • transjugular intrahepatic portal-systemic stent shunt
  • oesophageal transection with anastomosis
  • variceal transthoracic transoesophageal ligation
  • Tanner operation - involves gastric transection with reanastomosis
• if bleeding persists then balloon tamponade with a Sengstaken-Blakemore tube should be considered

NICE suggest (1):

Timing of endoscopy

• endoscopy should be offered to unstable patients with severe acute upper gastrointestinal bleeding immediately after resuscitation
• endoscopy should be offered within 24 hours of admission to all other patients with upper gastrointestinal bleeding

Management of variceal bleeding

• terlipressin should be offered to patients with suspected variceal bleeding at presentation. Stop treatment after definitive haemostasis has been achieved, or after 5 days, unless there is another indication for its use
• prophylactic antibiotic therapy should be offered at presentation to patients with suspected or confirmed variceal bleeding

Oesophageal varices

• band ligation should be employed in patients with upper gastrointestinal bleeding from oesophageal varices
• consider transjugular intrahepatic portosystemic shunts (TIPS) if bleeding from oesophageal varices is not controlled by band ligation

Gastric varices

• endoscopic injection of N-butyl-2-cyanoacrylate should be offered to patients with upper gastrointestinal bleeding from gastric varices
• offer TIPS if bleeding from gastric varices is not controlled by endoscopic injection of N-butyl-2-cyanoacrylate

Notes:

• SIGN also suggest (2):
  • balloon tamponade should be considered as a temporary salvage treatment for uncontrolled variceal haemorrhage
  • variceal band ligation combined with a beta blocker is recommended as secondary prevention for oesophageal variceal haemorrhage
  • in patients unsuitable for variceal band ligation combination of non-selective beta blocker and nitrate is recommended as secondary prevention for oesophageal variceal haemorrhage.

Reference:

• 1) NICE (August 2016). Acute Upper GI bleeding.
• 2) SIGN (2008). Management of acute upper and lower gastrointestinal bleeding