April 15, 2011

Acute esophageal variceal bleeding

45 years old Malay gentleman with history of alcoholic liver disease presented to the casualty with vomiting out blood. A diagnosis of Acute Variceal Bleeding was made and patient is in compensated shock state. Outline your management to this gentleman.

Aim of management
1) correct hypovolumic shock
2) achieve hemostasis at bleeding site

Acute Management

1) Triage the patient to the red zone with available crash cart
2) Evaluate the airway, breathing and circulation
a) Hemodynamically unstable patient may require elective intubation for airway protection
b) Two large bore IV canulla must available
c) Oxygen 3L/min via nasal prong
3) Monitoring of ECG, pulse oxymetry, blood pressure monitoring
4) Blood investigation (GSH and GXM 2 pack cell, FBC, PT/aPTT, RFT/LFT, CBS, VBG)
5) Fluid resuscitation with normal saline or ringer's lactate. Transfuse blood once available and keep hemoglobin around 8g/dL or hemocrit 24%
6) Strict monitoring of the input output. catherize the bladder and insert the CVP.
7) 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

8) Endoscopic therapy (sclerotherapy, variceal ligation)
9) If bleeding can not be stopped or delay in waiting for endoscopy, consider the usage of ballon temponade (Sengstenken Blackmore or minnesota) for maximum of 24 hours only
10) Transjugular intrahepatic portosystemic shunts for uncontrolled variceal bleeding after combined pharmacological and endoscopic therapy
11) Short term antibiotic prophylaxis for 7 days with IV third generation cephalosporin or oral quinolones (norfloxacin/ ciprofloxacin)
12) Disposition of the patient depending on the severity either to the surgical ward or ICU.

Notes: Management of patient in wards or ICU

1) Secondary prohylaxis to prevent re bleeding
2) Non-selective ß-adrenergic antagonists such as propranolol and nadolol
3) endoscopic sclerotherapy every 10-14 days until the varices are obliterated (5-6 sessions)or endoscopic variceal banding
4) Combination of pharmacological and endoscopic management may be considered
5) Transjugular Intrahepatic Portosystemic Shunts
6) Surgical therapy (selective shunts or devascularisation procedures)

Prophylaxis for esophageal varices in patient who do not develop bleeding yet.

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


Malaysia Clinical Practice Guidelines for Management of Acute Variceal bleeding, May 2007

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