Varices, Emergency Medicine

Gastroesophageal varices are present in 50% of patients with cirrhosis and correlate with severity of disease.

The most important predictor of hemorrhage is size of the varices. Other factors include number of varices, severity of hepatic disease and endoscopic findings.

Patients with PBC develop varices and variceal hemorrhage early in their course of disease, even prior to development of cirrhosis.

Physical Exam

Vitals signs may be normal or may show tachycardia (early) and hypotension (late).

Altered mental status with encephalopathy or poor perfusion

Active hematemesis

Stigmata of alcoholic liver disease:

Ascites

General edema

Jaundice

Essential Workup

Gastric tube placement:

Determines whether patient is actively bleeding

Decompresses stomach that may aid in hemostasis. Possible role in reducing aspiration risk

Facilitates endoscopic exam

Will not increase or cause esophageal variceal bleeding

Emergent endoscopy

Diagnosis Tests & Interpretation

Lab

Type and cross-match 6 " “8 U:

Significant transfusion requirements

ABG for:

Acidosis

Hypoxemia

CBC:

Hematocrit is an unreliable indicator of early rapid blood loss.

Perform serial CBCs to follow blood loss.

Electrolytes, BUN, creatinine, glucose:

Evaluate renal function.

BUN:creatinine ratio >30 suggest significant blood in GI tract.

PT/PTT/INR and platelets:

Coagulopathy

Prolonged bleeding times

Thrombocytopenia

Imaging

Chest radiograph (portable) for aspiration/perforation

ECG for myocardial ischemia

Differential Diagnosis

Bleeding/perforated peptic ulcer

Erosive gastritis

Mallory " “Weiss syndrome

Boerhaave syndrome

Aortoenteric fistula

Gastric varices

Gastric vascular ectasia

Treatment

Pre-Hospital

Airway stabilization

Treat hypotension 0.9% normal saline infusion bolus through 2 large-bore 16G or large IV lines.

Cardiac and pulse oximetry monitoring

Initial Stabilization/Therapy

ABCs with early aggressive airway control/intubation:

Early intubation = easier intubation

For AMS or massive hemoptysis

Facilitates emergency endoscopy

Establish central IV access with invasive intravascular monitoring for hypotension not responsive to initial fluid bolus.

Replace lost blood as soon as possible:

Initiate with O-negative blood until type-specific blood available.

10 mL/kg bolus in children

Fresh-frozen plasma and platelets may be required.

Place gastric tube nasally (awake) or orally (intubated)

Controversy:

Overly aggressive volume expansion may lead to rebound portal HTN, rebleeding, and pulmonary edema.

Transfusion goal is Hb = 8.

rFVIIa may decrease hemostasis failure rates in Child " “Pugh class B/C patients

Initiate intraosseous access if peripheral access unsuccessful in unstable patient.

Most bleeding in children stops spontaneously.

Vital sign changes may be a late finding in children:

Subtle changes in mental status, capillary refill, mild tachycardia, or orthostatic changes may indicate significant blood loss.

Overaggressive correction in infants can quickly lead to significant electrolyte abnormalities.

Ed Treatment/Procedures

Emergent endoscopy required for active bleeding:

Use pharmacologic and tamponade devices as temporizing measures.

Endoscopy

Emergent with active bleeding in nasogastric tube

Procedure of choice in acute esophageal bleeding

Esophageal band ligation equivalent to sclerotherapy with fewer complications:

May be difficult to visualize in cases of massive bleeding

Sclerotherapy with massive bleeding

Gastric varices are not amenable to endoscopic repair due to high rebleeding rate:

Treat pharmacologically.

Administer antibiotics at time of procedure to decrease risk for spontaneous bacterial peritonitis:

Fluoroquinolone or ceftriaxone

Pharmacological Therapy

Somatostatin is 1st-line therapy where available (not widely available in US) due to greater efficacy and fewer side effects when compared to octreotide

Octreotide is 1st-line therapy where somatostatin not available:

Complications include hyperglycemia and abdominal cramping.

Vasopressin replaced by octreotide/somatostatin secondary to high incidence of vascular ischemia

Balloon Tamponade

Initiate in massive uncontrollable bleed.

Sengstaken " “Blakemore and Minnesota tubes

Applies direct pressure but risks esophageal perforation and ulceration

Temporary benefit only with massive uncontrolled bleeding in the hands of experienced clinician

Refractory Bleeding Therapy

Interventional radiology:

Transjugular intrahepatic portosystemic shunt procedure. Recommended for refractory gastric varices or for patients who are poor surgical candidates

Surgical options:

Portacaval shunt

Variceal transection

Stomach devascularization

Liver transplantation

Medication

Ceftriaxone: 2 g (peds: 50 " “75 mg/kg/24 h) IV q24h in Child " “Pugh class B/C or in quinolone-resistant areas

Cefotaxime: 2 g (peds: 50 " “180 mg/kg/24 h) IV q8h

Erythromycin 250 mg IV:

Shown to aid in gastric clearing for better visualization during endoscopy

Norfloxacin 400 mg PO q12 or Ciprofloxacin 500 mg IV q12 if cannot tolerate PO (contraindicated in peds)

Octreotide: 50 ˇ ¼g bolus, then 50 ˇ ¼g/h infusion for 5 days

Somatostatin: 250 ˇ ¼g IV bolus followed by 250 ˇ ¼g/h IV infusion for 5 days

First Line

Somatostatin or octreotide (if somatostatin not available)

Norfloxacin PO or ciprofloxacin IV

Second Line

Erythromycin

Ceftriaxone

Follow-Up

Disposition

Admission Criteria

ICU admission for actively bleeding varices

Recent history of variceal bleeding

High risk for early rebleeding:

Age >60 yr, renal failure, initial hemoglobin count <8

Discharge Criteria Nonbleeding varices ‚ Issues for Referral

Continued hemorrhage requiring surgery or higher level of care

Liver transplant

Follow-Up Recommendations

Timely outpatient GI follow-up:

Will need annual surveillance endoscopies

Medication and lifestyle modifications

Pearls and Pitfalls

Intubate early, especially in patients with hepatic encephalopathy or hemodynamic instability.

Begin prophylactic antibiotics prior to endoscopy. Improves survival

In US, octreotide has replaced vasopressin owing to better side-effect profile. If vasopressin is required, use IV nitroglycerin infusion concomitantly to reduce end-organ ischemia.

Control the airway prior to placement of balloon tamponade device, which provides only a temporizing measure prior to surgery or TIPS

Hematochezia in a hemodynamically unstable patient is an upper GI bleed until proven otherwise.

Consult your GI specialists early, since endoscopy is the 1st-line diagnostic and therapeutic procedure.

Additional Reading

Garcia-Tsao ‚ G, Sanyal ‚ AJ, Grace ‚ ND, et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Am J Gastroenterol. 2007;102:2086 " “2102.

Nevens ‚ F. Review article: A critical comparison of drug therapies in currently used therapeutic strategies for variceal haemorrhage. Aliment Pharmacol Ther. 2004;20(suppl 3):18 " “22.

Sass ‚ DA, Chopra ‚ KB. Portal hypertension and variceal hemorrhage. Med Clin N Am. 2009;93:837 " “853.

See Also (Topic, Algorithm, Electronic Media Element)

Cirrhosis

Gastrointestinal Bleeding

Codes

ICD9

456.0 Esophageal varices with bleeding

456.1 Esophageal varices without mention of bleeding

456.21 Esophageal varices in diseases classified elsewhere, without mention of bleeding

456.8 Varices of other sites

456.20 Esophageal varices in diseases classified elsewhere, with bleeding

456.2 Esophageal varices in diseases classified elsewhere

ICD10

I85.00 Esophageal varices without bleeding

I85.01 Esophageal varices with bleeding

I85.10 Secondary esophageal varices without bleeding

I86.4 Gastric varices

I85.11 Secondary esophageal varices with bleeding

I85.1 Secondary esophageal varices

I85 Esophageal varices

I86.8 Varicose veins of other specified sites

SNOMED

28670008 Esophageal varices (disorder)

17709002 Bleeding esophageal varices (disorder)

308129003 Esophageal varices in cirrhosis of the liver