Liver Variceal Bleeding

2,020 views

Published on

www.medicinemcq.com

Published in: Health & Medicine
  • Be the first to comment

Liver Variceal Bleeding

  1. 1. Gastroesophageal varices develop in 55% of cirrhotic patients www.medicinemcq.com 1
  2. 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. 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. 4. Normal HVPG = 5 mm Hg  Portal hypertension  > 5 mm Hg  Esophageal hemorrhage  Only with HVPG > 12 mm Hg www.medicinemcq.com 4
  5. 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. 6. Portal pressure Portal venous inflow X outflow resistance. www.medicinemcq.com 6
  7. 7. Variceal bleeding  Massive hemetemesis With or without melena Painless www.medicinemcq.com 7
  8. 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. 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. 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. 11. First treatment in variceal bleed Airway Breathing Carotid pulse www.medicinemcq.com 11
  12. 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. 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. 14. IV fluids  Initial  Normal saline  Fresh frozen plasma - If PT > 3 sec  Avoid over transfusion  Increase portal pressure www.medicinemcq.com 14
  15. 15. Only after hemodynamically stable  Endoscopy or treatment to prevent further bleeding www.medicinemcq.com 15
  16. 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. 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. 18. Endoscopic intervention First line of treatment to control bleeding acutely www.medicinemcq.com 18
  19. 19. Endoscopic band ligation  Esophageal varices are ligated with endoscopically placed small elastic O-rings www.medicinemcq.com 19
  20. 20. www.medicinemcq.com 20
  21. 21. www.medicinemcq.com 21
  22. 22. Complications Esophageal ulceration and stricture 2. Fever 3. Chest pain 4. Mediastinitis 5. Pleural effusions 6. Aspiration 1. www.medicinemcq.com 22
  23. 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. 24. Proton pump inhibitors Most effective treatment for esophageal ulcer www.medicinemcq.com 24
  25. 25. Prophylactic banding Before bleeding Not recommended www.medicinemcq.com 25
  26. 26. Endoscopic Sclerotherapy  Varices are injected with a sclerosing agent  Endoscopic band ligation is preferred to sclerotherapy www.medicinemcq.com 26
  27. 27. www.medicinemcq.com 27
  28. 28. Complications of sclerotherapy Bacterial peritonitis  Esophageal perforation  Mediastinitis  Brain abscess  Spinal cord paralysis  Pericarditis  www.medicinemcq.com 28
  29. 29. Pharmacologic therapy  Decrease splanchnic blood flow  Reduce portal pressure by  Somatostatin analogues  Vasopressin www.medicinemcq.com 29
  30. 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. 31. Octreotide, lanreotide and vapreotide Synthetic long-acting analogues of somatostatin Octreotide is widely used www.medicinemcq.com 31
  32. 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. 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. 34. Short half-life Vasopressin must be given by continuous intravenous www.medicinemcq.com 34
  35. 35. Side effects Cardiac ischemia GIT ischemia Acute renal failure Hyponatremia www.medicinemcq.com 35
  36. 36. IV nitroglycerin or S/L isosorbide dinitrate Concurrent use of venodilators enhances the effectiveness and reduces complications www.medicinemcq.com 36
  37. 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. 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. 39. Balloon tamponade  When there is failure of vasopressin or endoscopy  Control active bleeding in > 90% www.medicinemcq.com 39
  40. 40. Serious complications Esophageal perforation Aspiration pneumonia Rarely asphyxiation www.medicinemcq.com 40
  41. 41. Sengstaken-Blakemore - triple-lumen or Minnesota-four-lumen www.medicinemcq.com 41
  42. 42. High risk of aspiration Perform endotracheal intubation before placing these tubes www.medicinemcq.com 42
  43. 43. Indication  Temporary measure  Active life-threatening hemorrhage  Refractory ○ Endoscopic and pharmacologic therapy www.medicinemcq.com 43
  44. 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. 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. 46. www.medicinemcq.com 46
  47. 47. TIPS - Indication When endoscopic or drug treatments have failed Poor surgical risks www.medicinemcq.com 47
  48. 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. 49. www.medicinemcq.com 49
  50. 50. Primary prevention of variceal bleed  To prevent the first bleeding episode  Only drug  Nonselective beta-blockers www.medicinemcq.com 50
  51. 51. Beta 2 receptor blockade  Eliminate beta 2 receptor– mediated vasodilation  Unopposed alphaadrenergic activity  Splanchnic vasoconstriction  Reduced portal pressure www.medicinemcq.com 51
  52. 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. 53. Contraindications to βblockers Endoscopic band ligation of the varices www.medicinemcq.com 53
  54. 54. Determinant of survival after a variceal bleed Hepatic function  Mortality rate after a variceal bleed ○50% within 6 weeks www.medicinemcq.com 54

×