Add in prepare for blood transfusion if haemodynamic unstable.
Why antibiotic prophylaxis?
Management of acute variceal bleeding
Clinical Practice Guideline, May 2004
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.
• 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
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
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.
ManagementActivebleedingepisodePreventionofrebleedingProphylacticmeasure toprevent the firsthaemorrhage
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
General Management:IV access and fluid resuscitationPrepare for blood transfusion if haemodynamicunstableCorrection of coagulopathy and thrombocytopeniaIntubation if severe uncontrollable bleeding,encephalopathic, inability to maintain O2 saturationadequately and to prevent aspiration
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
GenericnameTime tomaximumeffectDuration ofactionHalf -lifeSomatostatinTerlipressin 6 hourOctretideTerlipressin was not inferior to octreotide in itsefﬁ cacy for controlling variceal bleed.
Endoscopic Sclerotherapy or Endoscopicbanding or Adrenaline injection If bleeding uncontrolled a Minnesota tube orSangstaken-Blakemore tube is used.
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)
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)
Terlipressin vs. Octreotide in Bleeding EsophagealVarices as an AdjuvantTherapy With Endoscopic BandLigation:A Randomized Double-Blind Placebo-ControlledTrial