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Oesophageal variceal bleed

 

Definition of a variceal bleed

  • Oesophageal varices are dilated oesophageal veins secondary toportal hypertension.
  • Responsible for 5% of episodes of GI bleeding in the UK.

 

Causes of variceal bleeds

  • Pre-hepatic
    • Portal vein thrombosis / obstruction
    • Increased portal blood flow: fistula
  • Hepatic
    • Cirrhosis
      • 90% of cirrhotic patients get varices, 30% bleed
    • Acute hepatitis (esp. alcoholic)
    • Schistosomiasis
    • Congenital hepatic fibrosis
  • Post-hepatic
    • Compression (e.g. from tumour)
    • Budd-Chiari syndrome
    • Constrictive pericarditis (and rarely right-sided heart failure)

 


Variceal bleeding management

 

Management of variceal bleeds (see acute UGI bleed section as well)

  • Resuscitation
    • ABC
      • Oxygen, blood tests (VBG, FBC, U+Es, LFTs, clotting, X-match)
      • Erect CXR
      • Fluid resuscitation
      • HDU/ITU
      • Monitoring
        • CVP line and catheter
  • Correct anaemia and coagulopathy
    • Transfusion trigger should be 7 (aim 7-9)
      • Using a trigger of 9 significantly increases mortality at 45 days (NEJM 2013).
  • Terlipressin (glypressin) 2g IV
    • Vasopressin analogue. Reduces portal pressure. Contraindicated in shock and peripheral vascular disease
    • Octreotide (a somatostatin analogue) can also be used second line
  • Antibiotics
    • Broad spectrum. IV Tazocin 4.5g. Blood is an excellent culture medium so these patients often end up septic without antibiotics. It may also be a subacute bacterial infection that has brought the patient into hospital initially.
  • Endoscopy (once stable and not bleeding)
    • Band ligation
      • This is the first choice of treatment
    • Sclerotherapy
      • In this therapy the varices are sclerosed
      • Various sclerosants can be used
      • Complications include transient fever, dysphagia, chest pain, ulceration and stricture.
    • Variceal obturation with glue
      • This involves embolisation of varices with a glue-like substance (N-butyl-2-cyanoacrylate)
      • Particularly good for gastric or gastro-oesophageal variceal bleeding
      • However, there is a risk of embolisation to the lung, spleen or brain
  • Transjugular intrahepatic portosystemic shunt (TIPSS)
    • Where bleeding is not controlled by endoscopy
    • Patient needs to be transferred to a specialist liver unit
    • Hepatic vein is cannulated percutaneously via the internal jugular vein using a needle under ultrasound guidance and a tract is created through the liver from the hepatic to the portal vein reducing portal pressure.
    • High success rate but encephalopathy found in 25% cases (as portal blood diverted from the liver) and shunt occludes within 1 year in up to 50% cases
  •  Prevention of variceal bleeding
    • Beta blockers
      • These lower portal blood pressure and risk of further bleeding by reducing portal blood flow.
    • Nitrates
      • Just for secondary prophylaxis.
      • Nitrates can also be used in the acute variceal haemorrhage with vasopressin and terlipressin.
    • Endoscopic screening
      • All patients with newly-diagnosed cirrhosis should have screening endoscopy, looking for oesophageal varices. In the long-term, repeated endoscopic screening is usually required, e.g. 2 to 3-yearly in cases of small varices.

 

 

Click here to download free teaching notes on Decompensated chronic liver disease: Oesophageal variceal bleed

Perfect revision for medical students, finals, OSCEs and MRCP PACES