This clinical practice guideline summarizes the management of variceal bleeding due to liver cirrhosis. Variceal bleeding occurs in 10-30% of people with cirrhosis and is a major cause of death. The causes of cirrhosis in Malaysia are mainly hepatitis B and alcohol use. Treatment involves stopping the bleeding episode, preventing rebleeding, and prophylaxis. Pharmacological therapies use vasoactive drugs. Endoscopic therapies include sclerotherapy, banding, and adrenaline injection. Antibiotic prophylaxis is also recommended.

1. Clinical Practice Guideline, May 2004

2.  10-30% of upper gastrointestinal
haemorrhage
 is a major cause of death in patients with
cirrhosis.
 The aetiology of cirrhosis in Malaysia is
mainly due to hepatitis B or alcohol
 In alcoholic liver disease, continued
abstinence from alcohol may result in a
decreasing in size or even disappearance of
varices.

3. • Severe consequence of portal hypertension secondary
to cirrhosis
• Core symptoms co-exist with other emotional,
behavioral & learning disorders
Definition
Co-
morbidities
• varies from 24-81% in oesophageal varices in patients
with cirrhosis
• 60% of decompensated cirrhosis and 30% of
compensated cirrhosis patients
Prevalence
Classification

4. Japanese US VATrial Paquet
Absent Absent Absent Absent
Grade 1: small, straight varices not
disappearing with insufflation
Small < 5 mm I
Grade 2: medium varices occupying
less than one third of the lumen
Medium 5-9 mm II
Grade 3: large varices occupying
more than one third of the lumen
Large >9 mm III
Giant IV

5. Increase
resistance to
portal flow
Increase portal
pressure
Varices
Variceal
growth
Decrease
arteriolar
resistance
Increase portal
blood inflow
Cirrhosis

6.  Severity of the liver dysfunction
 Size of the varices (large greater than
small)
 Presence of endoscopic red wale signs.
 Hepatic venous pressure gradient (HVPG)
- ---- variceal bleeding will not occur if the
HVPG is below 12mmHg.

7. Management
Active
bleeding
episode
Prevention
of
rebleeding
Prophylactic
measure to
prevent the first
haemorrhage

8.  Non-selective ß-adrenergic antagonists such as
propranolol and nadolol.
- Propranolol 20mg bd titrated to achieve a 25%
decrement in resting pulse rate or a pulse rate
of 55-60 bpm)
 Screening endoscopy 1-2 yearly from the onset
of diagnosis of liver cirrhosis

10.  General Management:
IV access and fluid resuscitation
Prepare for blood transfusion if haemodynamic
unstable
Correction of coagulopathy and thrombocytopenia
Intubation if severe uncontrollable bleeding,
encephalopathic, inability to maintain O2 saturation
adequately and to prevent aspiration

11. Specific therapy:
 Pharmacological therapy with vasoactive drugs to arrest
the bleeding (vasopressin/it's analogue, somatostatin/it's
analogue)
a) IV Terlipressin 2 mg stat bolus and 1 mg QID for 2-5
days or;
b) IV Somatostatin 250 mcg bolus followed with 250
mcq/h infusion for 2-5 days or;
c) IV bolus Octreotide 50 mcg stat followed with IV
infusion 50 mcg/h for 2-5 days

12. Generic
name
Time to
maximum
effect
Duration of
action
Half -life
Somatostatin
Terlipressin 6 hour
Octretide
Terlipressin was not inferior to octreotide in its
effi cacy for controlling variceal bleed.

13.  Endoscopic Sclerotherapy or Endoscopic
banding or Adrenaline injection
 If bleeding uncontrolled a Minnesota tube or
Sangstaken-Blakemore tube is used.

14. a) Non-selective ß-adrenergic antagonists such as
propranolol and nadolol
b) Endoscopic sclerotherapy every 10-14 days until
the varices are obliterated (5-6 sessions)or
endoscopic variceal banding
c) Combination of pharmacological and endoscopic
management may be considered
d) Transjugular Intrahepatic Portosystemic Shunts
(TIPSS)
e) Surgical therapy (selective shunts or
devascularisation procedures)

15.  Antibiotic prophylaxis in patients with cirrhosis
 Antibiotic treatment should be continued for 7
days
 Norfloxacin 400mg bd
 OR Ciprofloxacin 500mg bd or IV 200mg bd
 OR Third generation cephalosporins (e.g.
Ceftriaxone 1g daily)

16.  Terlipressin vs. Octreotide in Bleeding EsophagealVarices as an AdjuvantTherapy With Endoscopic Band
Ligation:A Randomized Double-Blind Placebo-ControlledTrial