Liver Variceal Bleeding

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  • 1. Gastroesophageal varices develop in 55% of cirrhotic patients www.medicinemcq.com 1
  • 2. Esophageal varices  Superficial veins that lack support from surrounding tissues  Prominent  2 to 3 cm above the gastroesophageal junction www.medicinemcq.com 2
  • 3. Stomach  Next most common site for varices  In continuity with esophageal varices (i.e., true gastroesophageal varices) or as freestanding gastric varices www.medicinemcq.com 3
  • 4. Normal HVPG = 5 mm Hg  Portal hypertension  > 5 mm Hg  Esophageal hemorrhage  Only with HVPG > 12 mm Hg www.medicinemcq.com 4
  • 5. Ohm's law : P = Q X R P = Pressure along a vessel  Q = Flow  R = Resistance to the flow www.medicinemcq.com 5
  • 6. Portal pressure Portal venous inflow X outflow resistance. www.medicinemcq.com 6
  • 7. Variceal bleeding  Massive hemetemesis With or without melena Painless www.medicinemcq.com 7
  • 8. RISK FACTORS HVPG > 12 mm Hg 2. Large esophageal varices 3. Child-Pugh class C cirrhosis 4. Presence of tense ascites 1. www.medicinemcq.com 8
  • 9. “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 www.medicinemcq.com 9
  • 10. Endoscopy  Best test to find the cause of upper GI hemorrhage  Patients with varices may bleed from other gastrointestinal lesions also (e.g., peptic ulcer, gastritis) www.medicinemcq.com 10
  • 11. First treatment in variceal bleed Airway Breathing Carotid pulse www.medicinemcq.com 11
  • 12. Priority  First  Protection of airway to prevent aspiration  Second  Restoration of circulating blood volume  Done before diagnostic endoscopy studies or treatment to stop the bleeding. www.medicinemcq.com 12
  • 13. Assess volume status  Heart rate  Pulse volume  BP – postural hypotension  Urine output  JVP (CVP)  Swan-Ganz pulmonary artery catheter www.medicinemcq.com 13
  • 14. IV fluids  Initial  Normal saline  Fresh frozen plasma - If PT > 3 sec  Avoid over transfusion  Increase portal pressure www.medicinemcq.com 14
  • 15. Only after hemodynamically stable  Endoscopy or treatment to prevent further bleeding www.medicinemcq.com 15
  • 16. Risk of rebleeding > 60% over 2 years  Greatest risk ○ Within hours or days after an acute bleed  50% of variceal bleeding stops by itself www.medicinemcq.com 16
  • 17. Endoscopy  To determine the cause of bleeding  As soon as the patient is stabilized  Variceal ligation  May be performed during the initial endoscopy www.medicinemcq.com 17
  • 18. Endoscopic intervention First line of treatment to control bleeding acutely www.medicinemcq.com 18
  • 19. Endoscopic band ligation  Esophageal varices are ligated with endoscopically placed small elastic O-rings www.medicinemcq.com 19
  • 20. www.medicinemcq.com 20
  • 21. www.medicinemcq.com 21
  • 22. Complications Esophageal ulceration and stricture 2. Fever 3. Chest pain 4. Mediastinitis 5. Pleural effusions 6. Aspiration 1. www.medicinemcq.com 22
  • 23. Esophageal ulcers  Seen in most treated patients  Uncomplicated  Recurrent bleeding from mucosal ulceration  In up to 20%  Esophageal strictures leading to dysphagia  15% www.medicinemcq.com 23
  • 24. Proton pump inhibitors Most effective treatment for esophageal ulcer www.medicinemcq.com 24
  • 25. Prophylactic banding Before bleeding Not recommended www.medicinemcq.com 25
  • 26. Endoscopic Sclerotherapy  Varices are injected with a sclerosing agent  Endoscopic band ligation is preferred to sclerotherapy www.medicinemcq.com 26
  • 27. www.medicinemcq.com 27
  • 28. Complications of sclerotherapy Bacterial peritonitis  Esophageal perforation  Mediastinitis  Brain abscess  Spinal cord paralysis  Pericarditis  www.medicinemcq.com 28
  • 29. Pharmacologic therapy  Decrease splanchnic blood flow  Reduce portal pressure by  Somatostatin analogues  Vasopressin www.medicinemcq.com 29
  • 30. 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 www.medicinemcq.com 30
  • 31. Octreotide, lanreotide and vapreotide Synthetic long-acting analogues of somatostatin Octreotide is widely used www.medicinemcq.com 31
  • 32. Octreotide  Half-life of 1.5 hours  Direct splanchnic vasoconstrictor  Excellent safety profile  No systemic circulatory effects  Side effects are mild hyperglycemia and abdominal cramping www.medicinemcq.com 32
  • 33. 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 www.medicinemcq.com 33
  • 34. Short half-life Vasopressin must be given by continuous intravenous www.medicinemcq.com 34
  • 35. Side effects Cardiac ischemia GIT ischemia Acute renal failure Hyponatremia www.medicinemcq.com 35
  • 36. IV nitroglycerin or S/L isosorbide dinitrate Concurrent use of venodilators enhances the effectiveness and reduces complications www.medicinemcq.com 36
  • 37. Terlipressin reduce mortality in acute variceal bleeding  Synthetic vasopressin analogue  Longer half-life  Used in bolus form  Fewer side effects www.medicinemcq.com 37
  • 38. Terlipressin  Vasoconstriction  Splanchnic vasculature  No risk to renal function and renal excretion of sodium  More effective and safer than vasopressin or vasopressin plus nitroglycerin www.medicinemcq.com 38
  • 39. Balloon tamponade  When there is failure of vasopressin or endoscopy  Control active bleeding in > 90% www.medicinemcq.com 39
  • 40. Serious complications Esophageal perforation Aspiration pneumonia Rarely asphyxiation www.medicinemcq.com 40
  • 41. Sengstaken-Blakemore - triple-lumen or Minnesota-four-lumen www.medicinemcq.com 41
  • 42. High risk of aspiration Perform endotracheal intubation before placing these tubes www.medicinemcq.com 42
  • 43. Indication  Temporary measure  Active life-threatening hemorrhage  Refractory ○ Endoscopic and pharmacologic therapy www.medicinemcq.com 43
  • 44. Rebleeding in up to 50% on deflation of the balloons Definitive treatment planned for most patients  Endoscopic therapy  TIPS  Operation www.medicinemcq.com 44
  • 45. Transjugular intrahepatic portosystemic shunt (TIPS)  Portal decompression without an operation  Therapy of choice for acute variceal bleeding after failure of drug and endoscopic therapy www.medicinemcq.com 45
  • 46. www.medicinemcq.com 46
  • 47. TIPS - Indication When endoscopic or drug treatments have failed Poor surgical risks www.medicinemcq.com 47
  • 48. 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 encephalopathy  25 % risk www.medicinemcq.com 48
  • 49. www.medicinemcq.com 49
  • 50. Primary prevention of variceal bleed  To prevent the first bleeding episode  Only drug  Nonselective beta-blockers www.medicinemcq.com 50
  • 51. Beta 2 receptor blockade  Eliminate beta 2 receptor– mediated vasodilation  Unopposed alphaadrenergic activity  Splanchnic vasoconstriction  Reduced portal pressure www.medicinemcq.com 51
  • 52. Propranolol, Nadolol or Timolol  Decrease the incidence of bleeding  Prolong survival  Continued life long  Useful in secondary prevention also www.medicinemcq.com 52
  • 53. Contraindications to βblockers Endoscopic band ligation of the varices www.medicinemcq.com 53
  • 54. Determinant of survival after a variceal bleed Hepatic function  Mortality rate after a variceal bleed ○50% within 6 weeks www.medicinemcq.com 54