Variceal Bleeding
25-50% mortality.
Varices result from collateral vessel formation as a consequence of portal hypertension caused by:
Aetiology
Intrahepatic
Cirrhosis (most common). 90% develop varices in 2 years.
Alcoholic hepatitis.
Prehepatic
Portal vein thrombosis (pancreatitis, malignancy, trauma, hyper coagulation).
Post hepatic
Hepatic vein occlusion (Budd-Chiari), constrictive pericarditis.
Prophylaxis is ß-blockade to reduce portal pressure.
Resus
Correct coagulopathy:
Give vitamin K 10mg to treat potential deficiency in alcoholics with poor nutrition (will only improve coagulopathy if vit k deficient).
FFP until INR <1.5.
Aim for Hb of 7-8 (over-transfusion increases portal pressure but remember RBCs needed for effective coagulation via margination of platelets).
Uncontrolled haemorrhage → airway compromise → intubation.
Terlipressin (analogue of vasopressin) 2mg every 4h for 48h reduces mortality by improving haemostasis (reduced portal pressure). It will also counteract the reduced venous return from splancnic dilatation thus improving cardiac output.
Somatostatin by infusion also lowers portal pressure but not routinely used.
Ongoing care
Antibiotics
Infection occurs in 50%.
ABX prophylaxis reduces mortality and re-bleeding.
Broad spectrum cover required.
Endoscopy
Band ligation (treatment of choice in acute bleed), sclerotherapy, or glue.
Balloon tamponade
Effective in 90%
Usually just gastric balloon is inflated and traction applied to gastro-oesophageal junction. Oesophageal inflated if this not effective alone → more complications. Oesophageal must be deflated temporarily every 12h.
Temporary measure until further endoscopy or TIPS.
TIPS
Transjugular intrahepatic porto-systemic shunt.
Portal and hepatic veins connected by stent.
Effective in 90% at stopping bleeding.
↑ encephalopathy.
ß-blockade
Propranolol (must be non-selective).
Not until recovered from acute event.