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