EBM Oesophagogastric Varices

Pedagogical disambiguation: Emergency Medicine Lecture Notes and Evidence Based emergency medicine principles from Professor A.F.T Brown and the Life in the Fast Lane team.

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 50-90% of bleeding episodes in those patients.
• Mortality of a first bleed 15-30%, with rebleeding in 30-60% after banding / sclerotherapy (highest risk in first 10 days), and a 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 absence of or awaiting (ie. during transfer); or as adjunct to (ie. octreotide) endoscopy.
  • Octreotide 50 μg, then 25-50 μg/hr IV. Long-acting somatostatin analogue. 80% success with decrease in bleeding, borderline mortality benefit. Continue for 24-48 hours.
  • Somatostatin.  More expensive, shorter half-life.
  • Terlipressin (Glypressin) 2 mg 6-hrly or vasopressin +/- GTN, to reduce portal pressure and deal with coronary ischaemia.
  • [Beta blocker (propanolol /nadolol) +/- isosorbide. Used for primary and secondary prophylaxis of bleeding, but not in acute bleeding].

Antibiotics:

• Norfloxacin 400 mg orally bd or ciprofloxacin IV at same dose, preferably before endoscopy, in any cirrhotic patient with an upper GI bleed. Ceftriaxone 1 g IV an 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]

Balloon tamponade (Sengstaken-Blakemore tube):

• Temporising procedure only. Up to 25% complications including death from aspiration, migration and or perforation, 50% rebleed. Need airway protection by endotracheal intubation.

Variceal decompression:

• Transjugular intrahepatic portosystemic shunt (TIPS). May be preferred to surgery in refractory or rebleed patients, possibly preceded by transjugular variceal embolisation. Also when liver transplantation being considered.
• Surgery. Emergency direct portacaval shunt (EPCS) or oesophageal transection.
• Either technique reduces re-bleed risk and mortality, with little increase in hepatic encephalopathy risk. However, 30-day mortality up to 80%.

Scottish Intercollegiate Guidelines Network (SIGN). Management of acute upper and lower gastrointestinal haemorrhage. Sept 2008. A national clinical guideline. [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]