Oesophagogastric Varices: Lecture Notes

Epidemiology

• 5-12% upper G1 bleeds.
• 50% cirrhosis patients have varices, up to 85% in Child-Pugh C patients.
• 25-35% of patients with chronic liver disease will have a variceal bleed, which accounts for 80-90% of bleeding episodes in those patients.
• Mortality of a first bleed 30%, with rebleeding in 30-60% after banding / sclerotherapy, and 32-80% 1-year mortality.

Management

• Endoscopic:
  • Banding ligation. Lower rebleeding, mortality and complication rate than sclerotherapy.
  • Sclerotherapy. Rebleed in 20-50%; higher complication rate. May be followed by propranolol.
  • Tissue adhesive eg. cyanoacrylate or bucrylate especially for gastric varices; intravariceal thrombin.
• Vasoactive drugs: In the absence of or awaiting (ie. during transfer); or as adjunct to (ie. octreotide) endoscopy.
  • Octreotide 50 mcg, then 25-50 mcg IV/h. Long acting somatostatin analogue. 80% success with decrease in bleeding, borderline mortality benefit. Continue for 24-48 hours.
  • Somatostatin. More expensive, shorter half-life.
  • Vasopressin, or terlipressin (Glypressin) +/- GTN, to reduce portal pressure and deal with coronary ischaemia.
  • [Beta blocker (propanolol /nadolol) +/- isosorbide. Used for primary and secondary prophylaxis of bleeding, not in acute bleeding].
• Balloon tamponade (Sengstaken-Blakemore tube):
  • Temporising procedure only. Up to 25% complications including death from aspiration, migration and or perforation, 50% rebleed. Usual to need airway protection by endotracheal intubation.
• Variceal decompression:
  • Transjugular intrahepatic portosystemic shunt (TIPSS). May be preferred to surgery in refractory or rebleed patients, possibly preceded by transjugular variceal embolisation. Also when liver transplantation being considered.
  • Surgery. Oesophageal transection or selective portacaval shunt (PCS).
  • Either technique reduces rebleed risk, but increases hepatic encephalopathy incidence. However, 30-day mortality over 80%.
• Antibiotics:
  • Norfloxacin 400 mg orally bd 2 days or ciprofloxacin IV at same dose, starting at time of endoscopy. Ceftriaxone 1 g IV alternative

Fernandez J, Ruiz del Arbor L, Gomez C et al. Norfloxacin vs ceftriaxone in the prophylaxis of infections in patients with advanced cirrhosis and hemorrhage. Gastroenterology 2006;131:1049-56. [Reference]

Garcia-Tsao G, Sanyal A, Grace N et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology 2007;46:922-38. [Reference]

Gortzsche P, Hrobjartsson A. Somatostatin analogues for acute bleeding oesophageal varices. Cochrane Database Syst Rev 2005; CD000193. [Reference]

Sharara A, Rockey D. Gastroesophageal variceal haemorrhage. NEJM 2001; 345:669-681. [Reference] [Errata]

Jalan R, Hayes P. UK guidelines on the management of variceal haemorrhage in cirrhotic patients. British Society of Gastroenterology. Gut 2000; 46(Suppl 3-4): iii1- iii15. [Reference] [Web Review]