Position statement of Hepatology Society, Dhaka, Bangladesh, on the management of acute variceal bleeding in a resource-limited setting

Abstract

Variceal bleeding is one of the important signs of decompensation in patients with cirrhosis of the liver. It is always a medical emergency and sometimes results in death. Every year many patients die due to acute bleeding worldwide. The outcome depends on bleeding and its complications as well as the severity of the underlying liver disease. Careful volume resuscitation, administration of antibiotics and vasoactive drugs, and early endoscopic therapy prevent rebleeding and death. People living in rural areas are first referred to a district hospital from the Upazila health complex for any medical emergency. So, commencing the resuscitation process as well as administration of the vasoactive drug (terlipressin) at the first attending hospital before being referred to a higher center will decrease the mortality in patients presenting with acute variceal bleeding.

Keywords: Cirrhosis; Primary care physician; Resource-limited setting; Terlipressin; Variceal bleeding.

Fig. 1

Natural history of cirrhosis of the liver. There are two stages, namely, compensated and decompensated cirrhosis. The main signs of decompensation are ascites, variceal bleeding, and hepatic encephalopathy. The compensated stage of cirrhosis is the longest period. Patients with compensated cirrhosis may have mild portal hypertension (mild PH) or clinically significant portal hypertension (CSPH). In CSPH, patients may have varices or not. But patients with CSPH are at high risk of developing decompensation. The decompensated stage may rapidly progress to further decompensation. At this stage, patients may develop renal failure (hepatorenal syndrome) and liver failure (encephalopathy and jaundice), leading to high mortality [3].

Fig. 2

Child–Turcotte–Pugh classification.