Management of acute variceal bleeding

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  • Decompensated liver cirrhosisCompensated liver cirrhosis
  • Add in prepare for blood transfusion if haemodynamic unstable.
  • Why antibiotic prophylaxis?


  • 1. Clinical Practice Guideline, May 2004
  • 2.  10-30% of upper gastrointestinalhaemorrhage is a major cause of death in patients withcirrhosis. The aetiology of cirrhosis in Malaysia ismainly due to hepatitis B or alcohol In alcoholic liver disease, continuedabstinence from alcohol may result in adecreasing in size or even disappearance ofvarices.
  • 3. • Severe consequence of portal hypertension secondaryto cirrhosis• Core symptoms co-exist with other emotional,behavioral & learning disordersDefinitionCo-morbidities• varies from 24-81% in oesophageal varices in patientswith cirrhosis• 60% of decompensated cirrhosis and 30% ofcompensated cirrhosis patientsPrevalenceClassification
  • 4. Japanese US VATrial PaquetAbsent Absent Absent AbsentGrade 1: small, straight varices notdisappearing with insufflationSmall < 5 mm IGrade 2: medium varices occupyingless than one third of the lumenMedium 5-9 mm IIGrade 3: large varices occupyingmore than one third of the lumenLarge >9 mm IIIGiant IV
  • 5. Increaseresistance toportal flowIncrease portalpressureVaricesVaricealgrowthDecreasearteriolarresistanceIncrease portalblood inflowCirrhosis
  • 6.  Severity of the liver dysfunction Size of the varices (large greater thansmall) Presence of endoscopic red wale signs. Hepatic venous pressure gradient (HVPG)- ---- variceal bleeding will not occur if theHVPG is below 12mmHg.
  • 7. ManagementActivebleedingepisodePreventionofrebleedingProphylacticmeasure toprevent the firsthaemorrhage
  • 8.  Non-selective ß-adrenergic antagonists such aspropranolol and nadolol.- Propranolol 20mg bd titrated to achieve a 25%decrement in resting pulse rate or a pulse rateof 55-60 bpm) Screening endoscopy 1-2 yearly from the onsetof diagnosis of liver cirrhosis
  • 9.  General Management:IV access and fluid resuscitationPrepare for blood transfusion if haemodynamicunstableCorrection of coagulopathy and thrombocytopeniaIntubation if severe uncontrollable bleeding,encephalopathic, inability to maintain O2 saturationadequately and to prevent aspiration
  • 10. Specific therapy: Pharmacological therapy with vasoactive drugs to arrestthe bleeding (vasopressin/its analogue, somatostatin/itsanalogue)a) IV Terlipressin 2 mg stat bolus and 1 mg QID for 2-5days or;b) IV Somatostatin 250 mcg bolus followed with 250mcq/h infusion for 2-5 days or;c) IV bolus Octreotide 50 mcg stat followed with IVinfusion 50 mcg/h for 2-5 days
  • 11. GenericnameTime tomaximumeffectDuration ofactionHalf -lifeSomatostatinTerlipressin 6 hourOctretideTerlipressin was not inferior to octreotide in itseffi cacy for controlling variceal bleed.
  • 12.  Endoscopic Sclerotherapy or Endoscopicbanding or Adrenaline injection If bleeding uncontrolled a Minnesota tube orSangstaken-Blakemore tube is used.
  • 13. a) Non-selective ß-adrenergic antagonists such aspropranolol and nadololb) Endoscopic sclerotherapy every 10-14 days untilthe varices are obliterated (5-6 sessions)orendoscopic variceal bandingc) Combination of pharmacological and endoscopicmanagement may be consideredd) Transjugular Intrahepatic Portosystemic Shunts(TIPSS)e) Surgical therapy (selective shunts ordevascularisation procedures)
  • 14.  Antibiotic prophylaxis in patients with cirrhosis Antibiotic treatment should be continued for 7days Norfloxacin 400mg bd OR Ciprofloxacin 500mg bd or IV 200mg bd OR Third generation cephalosporins (e.g.Ceftriaxone 1g daily)
  • 15.  Terlipressin vs. Octreotide in Bleeding EsophagealVarices as an AdjuvantTherapy With Endoscopic BandLigation:A Randomized Double-Blind Placebo-ControlledTrial