Treatment of acute variceal bleeding.

Once the bleeding patient has been resuscitated and the diagnosis of acute variceal hemorrhage established by endoscopy, emergency injection sclerotherapy should be employed as the therapeutic option of choice. Endoscopic band ligation is a promising new technique that may prove to be as effective as sclerotherapy, with fewer complications. Pharmacologic treatment (with vasopressin and nitroglycerin) and balloon tamponade remain important alternative treatments, both as empiric temporizing therapy before sclerotherapy can be arranged and in the approximately 30% of patients who continue to bleed after a single sclerotherapy session. Continued bleeding in many of these patients can be controlled with a second session of sclerotherapy. If active acute bleeding persists after two sclerotherapy treatments, treatment should be considered a failure. Some of these patients may be suitable for surgical treatment with either staple-gun transection of the esophagus or emergency portacaval shunting.     

A simplified prognostic model to predict mortality in patients with acute variceal bleeding

BackgroundAcute variceal bleeding (AVB) is a major cause of death in patients with liver cirrhosis. The aim of this study was to investigate mortality predictors and develop a new simple prognostic model using easily verified factors at admission in AVB patients.MethodsBetween January 2009 and May 2015, 333 consecutive patients with AVB were included. A simplified prognostic model was developed using multiple logistic regression after identifying significant predictors of 6-week mortality. Mortality prediction accuracy was assessed with area under the receiver operating characteristic (AUROC) curve. We compared the new model to existing models of model for end-stage liver disease (MELD) and Child–Pugh scores.ResultsThe 6-week overall mortality rate was 12.9%. Multivariate analysis showed that C-reactive protein (CRP), total bilirubin, and the international normalized ratio were independent predictors of mortality. A new logistic model using these variables was developed. This model’s AUROC was 0.834, which was significantly higher than that of MELD (0.764) or Child–Pugh scores (0.699). Two external validation studies showed that the AUROC of our model was consistently higher than 0.8.ConclusionsOur new simplified model accurately and consistently predicted 6-week mortality in patients with AVB using objective variables measured at admission. Our system can be used to identify high risk AVB patients.     

Management of acute variceal haemorrhage

Endoscopic therapy and in particular endoscopic variceal banding ligation, in experienced hands, is the treatment of choice for acute variceal bleeding which remains a major cause of death in patients with cirrhosis and portal hypertension. Pharmacological therapy with Glypressin or somatostatin can be useful to gain time when the endoscopic expertise is not available or to help to obtain a clearer endoscopic view. Transjugular intrahepatic porto-systemic stent shunt is currently used for endoscopic failures, producing similar results with the surgical portacaval shunts. Which one of the two should be preferred, since they both work best in relatively compensated patients, should be a balance between the available surgical and radiological expertise, the urgency of the situation and the expected course of the disease.     

Treatment of acute variceal bleeding

The management of variceal bleeding remains a clinical challenge with a high mortality. Standardisation in supportive and new therapeutic treatments seems to have improved survival within the last 25 years. Although overall survival has improved in recent years, mortality is still closely related to failure to control initial bleeding or early re-bleeding occurring in up to 30-40% of patients. Initial procedures are to secure and protect the airway, and administer volume replacement to stabilize the patient. Treatment with vasoactive drugs should be started as soon as possible, since a reduction in portal pressure is associated with a better control of bleeding and may facilitate later endoscopic procedures. Vasopressin and its analogues Terlipressin and somatostatin and analogues are the two types of medicine, which has been evaluated. In meta-analysis, only Terlipressin have demonstrated effects on control of bleeding and on mortality. Somatostatin and its analogues improve control of bleeding, but show in meta-analysis no effects on mortality. Approximately 20% of patients with variceal bleeding will suffer from an infection, when they are hospitalized. Invasive procedures will further increase the risk of bacterial infections. Meta-analysis of clinical trials comparing antibiotics with placebo demonstrates that antibiotic prophylaxis improves survival with 9% (p<0.004). Quinolones or intravenous cephalosporins should be preferred. Early endoscopy should be performed in patients with major bleeding. Endoscopic therapy increases control of bleeding and decreases the risks of rebleeding and mortality. Ligation is probably more effective than sclerotherapy with fewer complications and should therefore be preferred, if possible. In case of gastric variceal bleeding, tissue adhesives should be used. In conclusion: Improvements in resuscitation and prevention of complications have together with introduction of vasoactive drugs and refinement of endoscopic therapy majorily changed the prognosis of the patient presenting with variceal bleeding.     

Management of acute variceal bleeding

Portal hypertension as a consequence of liver cirrhosis is responsible for its most common complications: ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, hepatic encephalopathy and the most important one--variceal hemorrhage. Variceal bleeding results in considerable morbidity and mortality. This review covers all areas of importance in the therapy of acute variceal hemorrhage--endoscopic and pharmacological treatment, transjugular intrahepatic portosystemic shunt, surgery and balloon tamponade. Indications and limitations of these therapeutic modalities are widely discussed.     

Esophageal variceal ligation for acute variceal bleeding: results of three years' follow-up.

BACKGROUND/AIMS: Endoscopic variceal ligation is widely accepted as the optimum endoscopic treatment for esophageal variceal hemorrhage. However, the rebleeding course and long-term outcome of patients with esophageal variceal hemorrhage after ligation have been poorly defined. Therefore, we conducted a long-term follow-up study to delineate the outcome of ligation. METHODS: Twenty-one liver cirrhotic patients with endoscopically proven esophageal variceal hemorrhage were treated by endoscopic variceal ligation. These patients received regular follow-up and detailed clinical assessment of at least 24 months. RESULTS: Twenty-one eligible patients were followed up for a mean of 44.45 months (range 33.5-64 months). The mean number of sessions required to obtain eradication was 3.57+/-1.99 (range 1-8). Esophageal varices could be obliterated within 11.57+/-6.8 weeks (range 3-30). The percentage of variceal recurrence during follow-up was 57.14% (12/21) after endoscopic variceal ligation. Recurrence were observed in a mean of 34 months (median 29 months). Rebleeding from esophageal varices appeared in four patients (19.04%). The appearance rates of portal hypertensive gastropathy and fundal gastric varices after varice obliteration were found to be 45.45% (5/11) and 25% (3/12), respectively. CONCLUSIONS: Based on the results of long-term follow-up of endoscopic variceal ligation, although the percentage of variceal recurrence was high, endoscopic ligation achieved variceal obliteration faster and in fewer treatment sessions. Furthermore, endoscopic variceal ligation had a lower rate of rebleeding and of development of fundal gastric varices, but high portal hypertensive gastropathy.     

7 Advances in drug therapy for acute variceal haemorrhage

Recent advances in the pharmacology of portal hypertension are reviewed, against the background of existing knowledge and current clinical research. The most recent trials are analysed, and conclusions made about the use of drugs in acute variceal haemorrhage, as well as directions for further clinical trials and research.     

Balloon tamponade and vasoactive drugs in the control of acute variceal haemorrhage

Successful pharmacological arrest of haemorrhage might avoid the risk of aspiration associated with tamponade and early studies have suggested that the vasoactive agent somatostatin may be as effective and perhaps safer than tamponade in controlling variceal haemorrhage. In our view, vasopressin has not established a role in management but we retain an open mind regarding the potential use of terlipressin in combination with nitroglycerin. It is unlikely that any of these agents can improve significantly our ability to control variceal haemorrhage when compared to balloon tamponade but they may reduce the incidence of pulmonary complications and thereby reduce subsequent mortality.Tamponade has proved successful in controlling acute haemorrhage from oesophageal varices in our hands. Late complications continue to give cause for concern but until effective safe alternatives to tamponade are developed, we continue to advocate its use for emergency control of acute variceal haemorrhage. Our own studies have shown that the high mortality seen in this patient population may reflect the severity of the underlying liver disease rather than failure of a management policy employing oesophageal tamponade for the initial control of acute variceal haemorrhage.     

A commonsense approach to variceal bleeding

A cirrhotic patient with large varices and red color signs at endoscopy, and a portal pressure greater than 12 mmHg, has a high risk of bleeding from those varices in the near future. Prophylactic therapy with a nonselective beta-adrenergic blocking drug or long acting nitroglycerin reduces the risk of developing the first bleed and increases life expectancy. The acute variceal bleed requires prompt resuscitation with volume replacement, early initiation of vasoactive drugs (octreotide, somatosatin, or vasopressin plus nitroglycerin) to reduce portal pressure and decrease splanchnic flow, and early diagnostic endoscopy to determine the cause of bleeding. Variceal banding or sclerotherapy is successful in controlling the acute bleed in up to 90% of cases. Beta-adrenergic blocker therapy should be instituted once the bleed has been controlled and banding/sclerotherapy continued until the varices have been obliterated. In the patient with recalcitrant or recurrent bleeding, TIPS, selective shunt surgery, or liver transplantation may be options depending on the specifics of the particular case.     

The treatment of acute variceal bleeding

Bleeding from gastroesophageal varices is a frequent and often deadly complication of cirrhosis. Although mortality from an episode of variceal bleeding has decreased in the last 2 decades it is still around 20%. This paper reviews the most recent advancements in the general management and hemostatic treatments of acute variceal bleeding.     

Periprocedural management of acute variceal bleeding

Acute variceal hemorrhage is a life-threatening complication of cirrhosis and certain non-cirrhotic conditions. The incidence of esophagogastric varices ranges from 20%-80% among cirrhotic patients, establishing it as a well-known health concern. Management of variceal bleeding has advanced over the past 30 years but an overall mortality rate of 10%-20% remains. Patient death is often due to complications of hemodynamic instability, coagulopathy, infection, malnutrition, or subsequent rebleeding. Herein, we highlight the periprocedural management of variceal hemorrhage and its complications.     

Octreotide for acute esophageal variceal bleeding: a meta-analysis

BACKGROUND & AIMS: Studies of octreotide have not demonstrated a consistent benefit in efficacy or safety compared with conventional therapies. This study statistically pooled existing trials to evaluate the safety and efficacy of octreotide for esophageal variceal hemorrhage. METHODS: We identified randomized trials of octreotide for variceal hemorrhage from computerized databases, scientific meeting abstracts, and the manufacturer of octreotide. Blinded reviewers abstracted the data, and a meta-analysis was performed. RESULTS: Octreotide improved control of esophageal variceal hemorrhage compared with all alternative therapies combined (relative risk [RR], 0.63; 95% confidence interval [CI], 0.51-0.77); vasopressin/terlipressin (RR, 0.58; 95% CI, 0.42-0.81); or no additional intervention/placebo (among patients that received initial sclerotherapy/banding before randomization) (RR, 0.46; 95% CI, 0.32-0.67). Octreotide had comparable efficacy to immediate sclerotherapy for control of bleeding (RR, 0.94; 95% CI, 0.55-1.62), fewer major complications than vasopressin/terlipessin (RR, 0.31; 95% CI, 0.11-0.87), and a complication profile comparable to no intervention/placebo (RR, 1.06; 95% CI, 0.72-1.55). No specific alternative therapy demonstrated a mortality benefit. CONCLUSIONS: These results favor octreotide over vasopressin/terlipressin in the control of esophageal variceal bleeding and suggest it is a safe and effective adjunctive therapy after variceal obliteration techniques. Trials are needed to determine the optimal dose, route, and duration of octreotide treatment.     

Thrombin--an effective treatment for gastric variceal haemorrhage.

The optimum treatment of gastric varices has still to be defined. Lesser curve gastric varices may be treated by injection sclerotherapy, but this has a limited role in the treatment of fundal gastric varices. Surgical intervention is commonly needed but carries a high mortality in patients with advanced liver disease. This study evaluated the use of thrombin for the treatment of gastric varices in 11 consecutive patients (nine with fundal, two with high lesser curve varices), identified as having bled from this site. Bovine thrombin (1000 U/ml) was injected intravariceally (mean volume 5.5 ml, range 2-10 ml) producing initial haemostasis in all 11 cases. Varices were considered thrombosed or obliterated in all patients after a median of two injection episodes (range 1-3). After a median follow up of nine months only one patient had rebled from a gastric varix. Thrombin may represent a valuable alternative injectate for the treatment of gastric varices.     

Nonendoscopic management of acute esophageal variceal bleeding

Acute esophageal variceal bleeding is a life-threatening complication of portal hypertension in patients with liver cirrhosis. Its management has improved over the past several years, leading to a significant reduction in rebleeding episodes and in bleeding-related deaths. Although endoscopic therapy is an integral part in the management of the acute variceal bleeder, pharmacologic and radiologic therapies are important interventions, in addition to optimal supportive care. Herein, we highlight the nonendoscopic management of acute esophageal variceal bleeding.