Management of acute variceal bleeding

Abstract

Acute variceal bleeding could be a fatal complication in patients with liver cirrhosis. In patients with decompensated liver cirrhosis accompanied by ascites or hepatic encephalopathy, acute variceal bleeding is associated with a high mortality rate. Therefore, timely endoscopic hemostasis and prevention of relapse of bleeding are most important. The treatment goals for acute variceal bleeding are to correct hypovolemia; achieve rapid hemostasis; and prevent early rebleeding, complications related to bleeding, and deterioration of liver function. If variceal bleeding is suspected, treatment with vasopressors and antibiotics should be initiated immediately on arrival to the hospital. Furthermore, to obtain hemodynamic stability, the hemoglobin level should be maintained at >8 g/dL, systolic blood pressure >90 to 100 mm Hg, heart rate <100/min, and the central venous pressure from 1 to 5 mm Hg. When the patient becomes hemodynamically stable, hemostasis should be achieved by performing endoscopy as soon as possible. For esophageal variceal bleeding, endoscopic variceal ligation is usually performed, and for gastric variceal bleeding, endoscopic variceal obturation is performed primarily. If it is considered difficult to achieve hemostasis through endoscopy, salvage therapy may be carried out while keeping the patient hemodynamically stable.

Keywords: Acute variceal bleeding; Endoscopy; Hemostasis.

Fig. 1

Endoscopic variceal ligation of esophageal varices. (A) Endoscopy reveals a red color sign on the esophageal varix through the transparent cap. (B) Variceal ligation is performed by placing the head of the endoscope with a rubber band ligation device over the varix to be ligated, suctioning the varix into the device, and tying the varix by discharging the rubber band.

Fig. 2

Endoscopic variceal obturation of gastric varices. (A) Endoscopy reveals spurt bleeding in the gastric varix in the fundus. (B) After puncturing the bleeding varix, the cyanoacrylate and lipiodol mixture is injected. (C) Endoscopic hemostasis is achieved after injection.

Fig. 3

Inadequate injection of cyanoacrylate. (A) Spurt bleeding is noted in the slightly protruding gastric varix. (B) Submucosal swelling around the varix is seen after injecting cyanoacrylate.