Recent advances in the management of variceal bleeding

Abstract

Acute haemorrhage from ruptured gastroesophageal varices is perhaps the most serious consequence of uncontrolled portal hypertension in cirrhotic patients. It represents a medical emergency and is associated with a high morbidity and mortality. In those who survive the initial bleeding event, the risks of further bleeding and other decompensated events remain high. The past 30 years have seen a slow evolution of management strategies that have greatly improved the chances of surviving a variceal haemorrhage. Liver cirrhosis is a multi-staged pathological process and we are moving away from a one-size-fits-all therapeutic approach. Instead there is an increasing recognition that a more nuanced approach will yield optimal survival for patients. This approach seeks to risk stratify patients according to their disease stage. The exact type and timing of treatment offered can then be varied to suit individual patients. At the same time, the toolbox of available therapy is expanding and there is a continual stream of emerging evidence to support the use of endoscopic and pharmacological therapies. In this review, we present a summary of the treatment options for a variety of different clinical scenarios and for when there is failure to control bleeding. We have conducted a detailed literature review and presented up-to-date evidence from either primary randomized-controlled trials or meta-analyses that support current treatment algorithms.

Keywords: acute varices haemorrhage; cirrhosis; non-selective beta-blockers; prophylaxis; variceal band ligation; varices.

Figure 1.

Treatment algorithm for the screening and management of gastroesophageal varices. GI, gastrointestinal; OGD, oesophago-gastro-duodenosopy; NSBB, non-selective beta-blockers; VBL, variceal band ligation. Adapted from Bosch J and Sauerbruch T. Esophageal varices: stage dependent treatment algorithm. J Hepatol 2016;64:746–8.

Figure 2.

Treatment algorithm for the management of acute variceal haemorrhage. NSBB, non-selective beta-blockers; VBL, variceal band ligation; ABCDE, Airway, Breathing, Circulation, Disability, Exposure; OGD, oesophago-gastro-duodenosopy; GOV, gastro-oesophageal varices; IGV, isolated gastric varices; TIPSS, transjugular intrahepatic portosystemic stent-shunt.