TREATMENT OF VARICEAL BLEED

Treatment of variceal bleed can be explained by 4 headings.

1. Prediction of patients at risk.

2. Prophylaxis against first bleed.
3. Treatment of active bleed.
4. Prevention of rebleeding.

I.PREDICTION OF PATIENTS AT RISK:

1. Location of varices-distal esophagus more prone to bleed.
2. Size of varices.
3. Appearance of varices.
4. Clinical features –degree of liver dysfunction,history of previous bleed.
5. Variceal pressure.
6. Risk factors for bleeding
Risk factors
Age>60 years
Renal failure
Severity of liver failure
Ascites
Hepatoma
Active alcoholism
Active bleeding on endoscopy
Increased variceal size
Red sign
Portal pressure

II.PROPHYLAXIS AGAINST A FIRST BLEED:

1. Each episode of variceal bleed is associated with 15-20% of mortality.
2. Portal pressure=inflow x outflow resistance
3. Normal portal pressure-5-10 mmhg.
4. Hepatic portal vein pressure gradient=Free HVP-Wedged HVP=1-5 mmHg.
5. Varices form when HVPG >10 mmHg.
6. In cirrhosis-increased inflow due to decreased tone & Increased outflow resisitance
7. Decreasing portal pressures=betablockers,nitrates,surgical portal decompression,TIPS.
8. Directly treating varices.
9. Beta blockers-increased unopposed alpha action and vasoconstriction and decreased
flow.
10. Carvidelol & propranolol are the only drugs recommended against first variceal
hemorrhage.
11. TIPS-causes portal decompression,not used as primary prophylaxis.
12. Endoscopic sclerotherapy-not recommended for primary prophylaxis.
13. EVL-can be used for large varices if not tolerating B-Blockers or C/I to beta blockers.
III.TREATING VARICEAL BLEED:
1. Medical therapy
2. Endoscopy-sclerotherapy,EVL
3. Surgical-shunt surgery,transplant.
4. Complication of sclerotherapy
 Local-ulceration,bleeding,gastroplasty.
 Regional-esophageal perforation,mediastinitis.
 Systemic-sepsis,aspiration.
Failure of endoscopy-one of the following criteria-
1. Fresh hematemesis or NG aspirate >100 ml >2 HOURS AFTER START of specific therapy
or endoscopy.
2. Development of hypovolemic shock.
3. 3 g drop in HB wihin 24 hours.
4. Time zero-time of admission into medical care.
5. Clinically significant bleeding-transfusion of >2 units or more with in 24 hrs of time
zero with SBP <100 or postural change >20 mmhg.
6. Acute bleeding-T Zero-120 HURS.
BALLOON TAMPONADE FOR ACUTE BLEEDING:
1. Only temporising measure until definite treatment.
2. 3 balloons are used.
 Sengestaken Blackmore-250 cc gastric balloon.esophageal balloon,single gastric
suction port.
 Minnesota –above +esophageal suction tube.
 Linton nachlas tube-600 cc gastric balloon.
METHOD OF INSERTION OF SB TUBE:
1. Patient need to be Intubated.
2. GEL applied.
3. Mouth or nostril upto 50 cm.
4. Gastric balloon inflated with 400-500 ml air.
5. Traction with 500 ml NS.
6. If bleeding don’t stop,inflate esophageal balloon with 30-45 mmHg and pressure
checked every hourly.
7. Once bleeding controlled reduce esophageal pressures to <25 mmHG by 5mmHg
slowly.
8. Gastric tube in place for 24-48 hours until definitive treatment.
9. Deflate every 12 hourly.
10. Complications-perforation,infarction.
IV.PREVENTING REBLEEDING-
1. Any bleeding that occurs more than 48 hours of initial admission after a 24 hour bleed
free period.
2. Early re bleeding-with in 6 weeks
3. Late rebleeding->6 weeks after onset of active bleeding.
Supportive care-
1. Hemodynamic resuscitation.
2. Pulmonary resuscitation.
3. Sepsis and role of antibiotics.
4. Renal management.
Metabolic-
1. Monitor for alcohol withdrawl,thiamine replacement,
2. Monitor for hypokalemia,hypophosphatemia,acid base disturbances.
Antibiotic prophylaxis:
1. Short term(7 days)-cirrhosis & GI hemorrhage-oral norflox 400 mg bd or iv
ciprofloxacin.
2. Advanced cirrhosis-IV ceftrioxone.