TOC   |  GI   

Esophageal Varices Bleeding                                         See also Upper GI Bleeding  

RX. Plan:

• Transfusion & fluid replacement as needed.
• 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 obliteration. or
  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 tamponade.
  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 propranolol.
• Liver transplant to reduce esophageal varices.

ACP Library on Disk 2- (c) 1997 - American College of Physicians                                                         

       11142001

NEJM  August 30, 2001 Review of GE Variceal Bleeding  
Ala I. Sharara, M.D., and Don C. Rockey, M.D.

• Figure 1. Therapies Used in the Management of Gastroesophageal Hemorrhage.  
• Figure 2. Suggested Algorithm for Primary Prophylaxis of Variceal Bleeding in Patients with Cirrhosis.
• Figure 3. Suggested Management of Acute Variceal Hemorrhage.
• Figure 4. Relative Effectiveness of Available Rx for the Prevention of Recurrent Variceal Bleeding.  
• Figure 5. Suggested Algorithm for the Prevention of Recurrent Variceal Bleeding.
• Table 1. Child–Pugh Classification of the Severity of Cirrhosis.  
• Table 2. Summary of Therapy for Esophageal Varices.  
• Table 3. Efficacy and Cost of Treatments for the Prevention of Recurrent Variceal Bleeding in Patients with Cirrhosis.