Esophageal Varices Bleeding
Upper GI Bleeding
Transfusion & fluid replacement as
Correct any coagulation disorder
with Vit. K, fresh frozen plasma, or platelet transfusion.
Temporary balloon tamponade to control
life-threatening active variceal bleeding.
Vasopressin/Pitressin start 0.3 u/min
(100 u in 250 mL D5W) for 30 min, if ineffective, increase at 30-60
min interval up to 0.9 u/hours for a max of 2-4 hours trial period
(Gastroenterology 1979;77:540) or 20 units IV bolus over 20 min,
followed by 0.8-1 u/min for a 2 hours trial in case of brisk bleeding. If
it is controlled, then 0.4 u/min for 24 hours, then discontinued.
Nitroglycerin past may be used q6h to decrease the incidence of
vasoconstrictive ischemic side effects.
Glypressin 2 mg IV bolus q4-6 hours.
Adverse effects: vasoconstriction with ischemia of the myocardium, abdominal
visceral, lower limbs, left heart failure, hypertension, & arrhythmia.
Somatostatin 250 ug IV bolus, then 250
ug/h x48-72 hours, or
Octreotide acetate (Sandostatin) 50 ug bolus, then 50 ug/h
x 48-72 hours.
Endoscopic sclerotherapy (injection of
varices with sclerosant) is done regularly, usually every 1 to 3 weeks, until
varices are obliterated, then at 3- to 6-month intervals to maintain
esophageal variceal rubber band ligation.
Rubber band ligation controls active bleeding and eradicates varices
as effectively as sclerotherapy. The mortality rate (45% vs 28%) and complication
rate (22% vs 2%), however, were considerably lower in patients treated with
rubber band ligation, which may therefore supersede variceal sclerotherapy.
Sengstaken-blakemore double balloon tube
or Linton single balloon tube
Gastic balloon placement needs x-ray confirmation.
Emergency surgery or TIPS (Transjugular
intrahepatic portosystemic shunt) or Distal spleno-renal shunt (DSRS)
Prophylaxis with Beta-blockers as
Liver transplant to reduce esophageal
ACP Library on Disk 2- (c) 1997 - American College of Physicians
August 30, 2001 Review of GE Variceal Bleeding
Ala I. Sharara, M.D., and Don C. Rockey, M.D.