liver variceal bleeding

1

VARICEAL BLEEDING

Gastroesophageal varices develop in 55% of cirrhotic

patients

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Esophageal varices

Superficial veins that lack

support from surrounding tissues

Prominent 2 to 3 cm above the

gastroesophageal junction


Stomach Next most common site for

varices In continuity with esophageal

varices (i.e., true gastroesophageal varices) or as freestanding gastric varices


Normal HVPG = 5 mm Hg

Portal hypertension> 5 mm Hg

Esophageal hemorrhageOnly with HVPG > 12 mm Hg


Ohm's law : P = Q X R

P = Pressure along a vessel Q = Flow R = Resistance to the flow


Portal pressure

Portal venous inflow X outflow resistance.


Variceal bleeding Massive hemetemesis

With or without melena Painless


RISK FACTORS

1. HVPG > 12 mm Hg

2. Large esophageal varices

3. Child-Pugh class C cirrhosis

4. Presence of tense ascites


“Red signs” Variceal appearance on endoscopy

Red wale marks ○ Longitudinal red streaks on varices

Cherry-red spots ○ Red, discrete, flat spots on varices

Hematocystic spots○ Red, discrete, raised spots)

Diffuse erythema


Endoscopy Best test to find the cause of upper

GI hemorrhagePatients with varices may bleed from

other gastrointestinal lesions also (e.g., peptic ulcer, gastritis)


First treatment in variceal bleed

AirwayBreathingCarotid pulse


Priority First

Protection of airway to prevent aspiration

SecondRestoration of circulating blood

volume Done before diagnostic

endoscopy studies or treatment to stop the bleeding.


Assess volume status

Heart rate Pulse volume BP – postural hypotension Urine output JVP (CVP) Swan-Ganz pulmonary artery

catheter


IV fluids Initial

Normal salineFresh frozen plasma - If PT > 3 sec

Avoid over transfusionIncrease portal pressure


Only after hemodynamically stable

Endoscopy or treatment to prevent further bleeding


Risk of rebleeding > 60% over 2 years

Greatest risk○Within hours or days after an

acute bleed 50% of variceal bleeding

stops by itself


Endoscopy To determine the cause of

bleedingAs soon as the patient is

stabilized Variceal ligation

May be performed during the initial endoscopy


Endoscopic intervention First line of treatment

to control bleeding acutely


Endoscopic band ligation

Esophageal varices are ligated with endoscopically placed small elastic O-rings


Complications

1. Esophageal ulceration and stricture

2. Fever

3. Chest pain

4. Mediastinitis

5. Pleural effusions

6. Aspiration


Esophageal ulcers Seen in most treated patients

Uncomplicated Recurrent bleeding from mucosal

ulcerationIn up to 20%

Esophageal strictures leading to dysphagia15%


Proton pump inhibitors Most effective

treatment for esophageal ulcer


Prophylactic banding

Before bleedingNot recommended


Endoscopic Sclerotherapy Varices are injected with a

sclerosing agent Endoscopic band ligation is

preferred to sclerotherapy


Complications of sclerotherapy Bacterial peritonitis Esophageal perforation Mediastinitis Brain abscess Spinal cord paralysis Pericarditis


Pharmacologic therapy Decrease splanchnic blood

flow Reduce portal pressure by

Somatostatin analoguesVasopressin


Somatostatin Hypothalamic hormone Inhibits the secretion of

vasodilatory peptides from the GIT Short half-life of 2 minutes Reduces renal plasma flow, GFR

and sodium excretion


Octreotide, lanreotide and vapreotide

Synthetic long-acting analogues of somatostatin

Octreotide is widely used


Octreotide Half-life of 1.5 hours Direct splanchnic vasoconstrictor Excellent safety profile

No systemic circulatory effectsSide effects are mild hyperglycemia

and abdominal cramping


Vasopressin - IV infusion Causes generalized

vasoconstriction Diminished blood flow in the portal

venous system Control of bleeding in up to 80% Bleeding recurs in 50 % after the

vasopressin is discontinued


Short half-life

Vasopressin must be given by continuous intravenous


Side effects

Cardiac ischemia GIT ischemia Acute renal failure Hyponatremia


IV nitroglycerin or S/L isosorbide dinitrate

Concurrent use of venodilators enhances the effectiveness and reduces complications


Terlipressin reduce mortality

in acute variceal bleeding

Synthetic vasopressin analogue

Longer half-life Used in bolus form Fewer side effects


Terlipressin Vasoconstriction

Splanchnic vasculature No risk to renal function and renal

excretion of sodium More effective and safer than

vasopressin or vasopressin plus nitroglycerin


Balloon tamponade

When there is failure of vasopressin or endoscopy

Control active bleeding in > 90%


Serious complications

Esophageal perforation Aspiration pneumonia Rarely asphyxiation


Sengstaken-Blakemore - triple-lumen or Minnesota-four-lumen


High risk of aspiration Perform endotracheal

intubation before placing these tubes


Indication Temporary measure

Active life-threatening hemorrhage

Refractory ○Endoscopic and pharmacologic

therapy


Rebleeding in up to 50% on deflation of the balloons

Definitive treatment planned for most patientsEndoscopic therapyTIPSOperation


Transjugular intrahepatic portosystemic shunt (TIPS)

Portal decompression without an operation

Therapy of choice for acute variceal bleeding after failure of drug and

endoscopic therapy


TIPS - Indication

When endoscopic or drug treatments have failed

Poor surgical risks


Complications Perforation of the liver capsule

Main early complication Stenosis of the shunt

Main long-term complication Common (50% at 1 year) Presents as further variceal haemorrhage

Hepatic encephalopathy25 % risk


Primary prevention of variceal bleed

To prevent the first bleeding episode

Only drugNonselective beta-blockers


Beta 2 receptor blockade Eliminate beta 2 receptor–

mediated vasodilation Unopposed alpha-

adrenergic activitySplanchnic vasoconstrictionReduced portal pressure


Propranolol, Nadolol or Timolol

Decrease the incidence of bleeding

Prolong survival Continued life long Useful in secondary

prevention also


Contraindications to β-blockers

Endoscopic band ligation of the varices


Determinant of survival after a variceal bleed

Hepatic functionMortality rate after a variceal bleed○50% within 6 weeks

liver variceal bleeding

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