Management of acute variceal hemorrhage

Abstract

Gastrointestinal bleeding is one of the major causes of death in patients with cirrhosis, and gastroesophageal varices represent the main source of hemorrhage. Even though in the last decades survival has been improved because of the widespread adoption of effective treatments and optimization of general medical care, mortality is still significantly high, and decompensated patients pose a complex challenge requiring a multidisciplinary approach that is crucial to improve survival. The aims of this commentary are to review the most recent advances in the management of esophageal variceal bleeding and to highlight useful information to aid hepatologists in clinical practice.

Keywords: TIPS; cirrhosis; non-selective betablockers; portal hypertension; variceal bleeding.

Figure 1.. Algorithm for the management of acute gastrointestinal bleeding in patients with cirrhosis.

ABC, airway, breathing, circulation; EVL, endoscopic variceal ligation; GI, gastrointestinal; IV, intravenous; NSBB, non-selective beta-blocker; PPI, proton pump inhibitor; PRBC, packed red blood cell; TIPS, transjugular intrahepatic portosystemic shunt; VH, variceal hemorrhage. *Any of the following: varix spurting blood, varices with overlying clot or with white nipple sign, varices and no other lesion that would explain hemorrhage. **A short-term course (10 days) of PPI may reduce the size of post-banding ulcers. ***Excluding patients who are more than 75 years old or who have hepatocellular carcinoma outside Milan criteria, creatinine level of at least 3 mg/dL, previous combination pharmacological plus endoscopic treatment to prevent re-bleeding, bleeding from isolated gastric or ectopic varices, recurrent hepatic encephalopathy, pulmonary hypertension, or heart failure or a combination of these. †Patient should not be discharged on prophylactic antibiotic (consider discontinuing at same time as vasoactive drugs).