Gastroenterology Hepatology

Liver transplantation: pretransplant management - variceal bleeding

How can I be sure that the patient has variceal bleeding?

Upper gastrointestinal hemorrhage due to bleeding from esophageal varices, gastric varices, and portal hypertensive gastropathy occurs in patients with portal hypertension from cirrhosis. Bleeding from gastroesophageal varices usually presents with hematemesis, melena, or both. Occult bleeding, particularly due to portal hypertensive gastropathy, may present as unexplained anemia. Bleeding from ectopic sites of variceal formation, other than the esophagus or stomach, is uncommon.

A tabular or chart listing of features and signs and symptoms

  • Hematemesis

  • Melena

  • Unexplained anemia

  • SIRS (See chapter "Liver transplantation: pretransplant management – systemic inflammatory response syndrome.")

How can I confirm the diagnosis?

Esophagogastroduodenoscopy is the most appropriate investigation to determine that a cirrhotic patient is experiencing or has had a recent gastroesophageal variceal hemorrhage. According to AASLD (American Association for the Study of Liver Disease) guidelines, all persons with suspected gastroesophageal variceal bleeding should undergo upper endoscopic inspection within 12 hours of hospital admission.

What other diseases, conditions, or complications should I look for in patients with variceal bleeding?

What other diseases, conditions, or complications should I look for in patients with possible gastroesophageal bleeding?

  • Bleeding erosive esophagitis

  • Peptic ulcer disease

  • Stress gastritis

  • GAVE (gastric antral vascular ectasia)

  • Dieulefoy's lesion

  • Aortoenteric fistula

  • Gastric or esophageal cancer

  • Swallowed blood from nasal bleeding

  • Osler-Weber-Rendu syndrome (i.e., hereditary hemorrhagic telangiectasia)

  • Peutz Jeghers Syndrome

What is the right therapy for the patient with variceal bleeding?

Therapy for variceal bleeding includes the following:

  • Admit to an intensive care unit

  • Resuscitate with blood products as appropriate.

  • Initiate pharmacologic therapy: octreotide IV; proton pump inhibitors IV; broad spectrum antibiotics IV.

  • Transfer to a center with appropriate endoscopy services, if such are not available at the first site, when patient is stable.

  • On transfer, admit to ICU, and request urgent consultation with provider of endoscopy.

  • When varices are confirmed by endoscopy, endoscopic ligation or injection of scleroscant is the appropriate therapy.

  • Failure to control hemorrhage endoscopically should lead to placement of an endotracheal breathing tube, assisted ventilation, and placement of a Blakemore-Sengstaken tamponade tube.

  • Failure to control hemorrhage, or massive recurrent hemorrhage, is an indication for TIPS (transjugular intrahepatic portocaval shunting.

What is the most effective initial therapy?

The most effective initial therapy involves the following:

  • Prior to endoscopy, start octreotide IV; proton pump inhibitors IV; broad spectrum antibiotics IV.

  • Endoscopic treatments are rubber band ligation and injection of sclerosants (sodium morrhuate, ethanolamine).

  • Temporary tamponade by a Blakemore-Sengstaken tube.

  • Transjugular intrahepatic portosystemic shunt (TIPS).

Listing of usual initial therapeutic options, including guidelines for use, along with expected result of therapy.

Based on the AASLD guidelines (2007):

  • Patients with suspected variceal hemorrhage need to be admitted to a hospital, with 24-hour access to endoscopic services, including treatment of varices.

  • Resuscitation prior to transfer is appropriate, particularly in patients who are hemodynamically unstable.

  • Resuscitation should include IV provision of blood products, and early intubation and assisted ventilation to maintain respiratory status and protect the airway from aspiration.

  • Prior to endoscopy, when there is reasonable suspicion for variceal hemorrhage, start IV octreotide, IV antibiotics, and IV proton pump inhibitors.

  • Patients with suspected variceal hemorrhage should have an EGD within 12 hours of hospital admission, and variceal treatment (ligation, injection of sclerosant) undertaken as appropriate.

A listing of a subset of second-line therapies, including guidelines for choosing and using these salvage therapies

Second-line therapies include:

  • Tamponade by Blakemore-Sengstaken tube

  • TIPS

Listing of these, including any guidelines for monitoring side effects.

N/A

How should I monitor the patient with variceal bleeding?

Monitoring for variceal bleeding involves:

  • Frequent, repeated vital signs (BP, pulse, O2 saturation, temperature, mental status)

  • Serial hemoglobins

  • Observation for hematemesis and melena

These observations should be undertaken in an intensive care unit for the first 24 hours.

What's the evidence?

Johnson, EA. "Optimizing the care of patients with cirrhosis and gastrointestinal hemorrhage: a quality control study". Aliment Pharmacol Ther. vol. 34. 2011. pp. 76-82.

Wang, YB, Zhang, JY, Gong, JP. " Balloon-occluded retrograde transvenous obliteration versus transjugular intrahepatic portosystemic shunt for treatment of gastric varices due to portal hypertension: a meta-analysis". J Gastroenterol Hepatol. 2015 Dec 5.

"Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis: AASLD guidelines 2007". http:/www.aasld.org/practiceguidlines.

**The original author for this chapter was Michael R. Lucey . The chapter was revised by Dr. Bruce R. Bacon.

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