Variceal Bleeding

25-50% mortality.
Varices result from collateral vessel formation as a consequence of portal hypertension caused by:

Cirrhosis (most common). 90% develop varices in 2 years.
Alcoholic hepatitis.
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.

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
Infection occurs in 50%.
ABX prophylaxis reduces mortality and re-bleeding.
Broad spectrum cover required.
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.
Transjugular intrahepatic porto-systemic shunt.
Portal and hepatic veins connected by stent.
Effective in 90% at stopping bleeding.
Propranolol (must be non-selective).
Not until recovered from acute event.