Importent for doctors

1. Gastroesophageal varices
develop in 55% of cirrhotic
patients
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2. Esophageal varices
Superficial veins that lack
support from surrounding
tissues
Prominent
2 to 3 cm above the
gastroesophageal junction
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3. Stomach
 Next most common site for
varices
 In continuity with esophageal
varices (i.e., true
gastroesophageal varices) or
as freestanding gastric varices
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4. Normal HVPG = 5 mm Hg
 Portal hypertension
 > 5 mm Hg
Esophageal hemorrhage
Only with HVPG > 12 mm Hg
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5. Ohm's law : P = Q X R
P = Pressure along a vessel
Q = Flow
R = Resistance to the flow
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6. Portal pressure
Portal venous inflow X
outflow resistance.
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7. Variceal bleeding
Massive hemetemesis
With or without melena
Painless
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8. RISK FACTORS
1. HVPG > 12 mm Hg
2. Large esophageal varices
3. Child-Pugh class C
cirrhosis
4. Presence of tense ascites
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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
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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)
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11. First treatment in variceal
bleed
Airway
Breathing
Carotid pulse
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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.
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13. Assess volume status
 Heart rate
 Pulse volume
 BP – postural hypotension
 Urine output
 JVP (CVP)
 Swan-Ganz pulmonary artery
catheter
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14. IV fluids
 Initial
 Normal saline
 Fresh frozen plasma - If PT > 3 sec
 Avoid over transfusion
 Increase portal pressure
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15. Only after hemodynamically stable
 Endoscopy or treatment to prevent
further bleeding
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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
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17. Endoscopy
To determine the cause of
bleeding
As soon as the patient is
stabilized
Variceal ligation
May be performed during the
initial endoscopy
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18. Endoscopic intervention
First line of treatment
to control bleeding
acutely
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19. Endoscopic band ligation
 Esophageal varices are ligated with
endoscopically placed small elastic
O-rings
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22. Complications
1. Esophageal ulceration and stricture
2. Fever
3. Chest pain
4. Mediastinitis
5. Pleural effusions
6. Aspiration
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23. Esophageal ulcers
 Seen in most treated patients
 Uncomplicated
 Recurrent bleeding from mucosal
ulceration
 In up to 20%
 Esophageal strictures leading to
dysphagia
 15%
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24. Proton pump inhibitors
Most effective
treatment for
esophageal ulcer
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25. Prophylactic banding
Before bleeding
Not recommended
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26. Endoscopic Sclerotherapy
 Varices are injected with a
sclerosing agent
 Endoscopic band ligation is
preferred to sclerotherapy
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28. Complications of
sclerotherapy
 Bacterial peritonitis
 Esophageal perforation
 Mediastinitis
 Brain abscess
 Spinal cord paralysis
 Pericarditis
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29. Pharmacologic therapy
Decrease splanchnic blood
flow
Reduce portal pressure by
Somatostatin analogues
Vasopressin
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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
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31. Octreotide, lanreotide and
vapreotide
Synthetic long-acting
analogues of
somatostatin
Octreotide is widely
used
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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
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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
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34. Short half-life
Vasopressin must be
given by continuous
intravenous
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35. Side effects
Cardiac ischemia
GIT ischemia
Acute renal failure
Hyponatremia
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36. IV nitroglycerin or S/L isosorbide
dinitrate
Concurrent use of
venodilators enhances
the effectiveness and
reduces complications
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37. Terlipressin reduce mortality
in acute variceal bleeding
 Synthetic vasopressin
analogue
 Longer half-life
 Used in bolus form
 Fewer side effects
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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
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39. Balloon tamponade
When there is failure of
vasopressin or endoscopy
Control active bleeding in >
90%
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40. Serious complications
Esophageal
perforation
Aspiration pneumonia
Rarely asphyxiation
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41. Sengstaken-Blakemore - triple-lumen or
Minnesota-four-lumen
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42. High risk of aspiration
Perform endotracheal
intubation before
placing these tubes
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43. Indication
 Temporary measure
 Active life-threatening
hemorrhage
 Refractory
○Endoscopic and pharmacologic
therapy
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44. Rebleeding in up to 50% on deflation
of the balloons
Definitive treatment
planned for most patients
Endoscopic therapy
TIPS
Operation
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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
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47. TIPS - Indication
When endoscopic or
drug treatments have
failed
Poor surgical risks
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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
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50. Primary prevention of variceal
bleed
To prevent the first bleeding
episode
Only drug
Nonselective beta-blockers
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51. Beta 2 receptor blockade
Eliminate beta 2 receptor–
mediated vasodilation
Unopposed alpha-
adrenergic activity
Splanchnic vasoconstriction
Reduced portal pressure
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52. Propranolol, Nadolol or Timolol
Decrease the incidence of
bleeding
Prolong survival
Continued life long
Useful in secondary
prevention also
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53. Contraindications to β-
blockers
Endoscopic band
ligation of the
varices
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54. Determinant of survival after a
variceal bleed
Hepatic function
Mortality rate after a
variceal bleed
○50% within 6 weeks
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