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Management of variceal bleeding

Management of variceal bleeding. Dr. Bennet Rajmohan, MRCSEd, MRCS (Eng) Consultant General Surgeon. Introduction. 30% of patients with cirrhosis develop portal hypertension 30% of patients with portal hypertension will bleed from varices within 2 years

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Management of variceal bleeding

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  1. Management of variceal bleeding Dr. Bennet Rajmohan, MRCSEd, MRCS (Eng) Consultant General Surgeon

  2. Introduction 30% of patients with cirrhosis develop portal hypertension 30% of patients with portal hypertension will bleed from varices within 2 years Incidence of varices in cirrhotics – 8% / year

  3. Active variceal bleed 1 of 3 major complications of portal hypertension – others  ascites & encephalopathy 1/3rd of all deaths related to cirrhosis Bleed occurs earlier in course of cirrhosis or with normal liver  wider treatment options than for ascites & encephalopathy

  4. Overview Treatment of an active bleed Prediction of patients at risk Prophylaxis against a first bleed Prevention of rebleeding

  5. Definitions • Time zero – time of admission to hospital • Clinically significant bleeding • 2 units of blood or more within 24 hrs of time zero • systolic BP <100 mmHg • postural systolic change of >20 mmHg • and/or a pulse rate >100/min at time zero

  6. Treatment of an active bleed

  7. GENERAL PRINCIPLES 3 primary goals Haemodynamic resuscitation Prevention & treatment of complications Treatment of bleeding

  8. Hemodynamic resuscitation Packed cells and clotting factors Platelet transfusions, if < 50,000/mm3 + active bleeding Avoid volume overload  risk of rebound portal hypertension and rebleed

  9. Recombinant factor VIIa Coagulopathy in severely volume overloaded  FFPs inadequate At least 2 RCTs – no clear benefit of recombinant factor VII awaits further clarification

  10. Prevention & management of complications

  11. Complications  death Aspiration pneumonia Sepsis Hepatic encephalopathy Renal failure

  12. Aspiration • Massive bleeding – Endotracheal intubation to protect airway  use unclear • NG tube – unclear • Can decompress stomach for subsequent endoscopy

  13. 2. Sepsis • Bacterial infections – 20% of cirrhotics hospitalized with GI bleed • Additional 50% develop infection in hospital • Most common • UTI (12 – 29%) • SBP (7 – 23%) • respiratory (6 – 10%) • primary bacteraemia (4 – 11%)

  14. Antibiotics overall ↓ in infectious complications possibly ↓ mortality ↓ risk of recurrent bleeding IV Ciprofloxacin x 7 days or Oral Norfloxacin (400mg bd) Advanced cirrhosis, IV Ceftriaxone (1G od)

  15. 3. Hepatic encephalopathy • aggressive search for potentially reversible factors • GI bleed • hypokalemia • metabolic alkalosis • Lactulose or L – Ornithine

  16. 4. Renal failure • acute tubular necrosis or hepatorenal syndrome • minimized by • appropriate volume replacement • avoid aminoglycosides • avoid mismatched transfusions

  17. Other measures Alcoholics Thiamine monitor for withdrawal symptoms Nutritionally depleted subjects hypophosphatemia & hypokalemia dextrose infusions raise serum insulin  drives both phosphate & potassium into cells

  18. Treatment of bleeding

  19. Treatment Hepatic vein pressure gradient >12mmHg 50% variceal bleed stops spontaneously vs > 90% in other forms of UGI bleed Options Pharmacotherapy Endoscopy Balloon tamponade Surgery

  20. Pharmacotherapy Terlipressin synthetic vasopressin analog – released in slow & sustained manner, 8th hrly doses sustained effect on portal pressure & blood flow vs transient effect with octreotide Only drug which reduces mortality

  21. Pharmacotherapy Somatostatin 250 mcg bolus f/b 250 mcg/h by IV infusion x 5 days Octreotide More easily available 50 mcg bolus f/b 50 mcg/h by IV infusion x 5 days

  22. Endoscopic Treatment Endoscopist experience and expertise Grade of varices Grade 1 – Small, straight varices Grade 2 – tortuous varices occupying <1/3rd of lumen Grade 3 – Large, coil-shaped varices occupying > 1/3rd of lumen

  23. Endoscopic Sclerotherapy • injection of sclerosant into varices • Complications • Local — ulceration, bleeding, dysmotility, stricture & portal hypertensive gastropathy • Regional — esophageal perforation & mediastinitis

  24. Endoscopic band ligation placing small elastic bands around varices in distal 5cm of oesophagus complications significantly lower much lower rate of oesophageal stricture reduction in rebleeding with Octreotide infusion + endoscopic banding

  25. Endoscopic band ligation

  26. Failure of endoscopic therapy • Within48 hrs from time zero • Reasons • Spurting varices • High Child-Pugh score • High hepatic venous pressure gradient • Infection • Portal vein thrombosis

  27. Failure of therapy • Within the first 6 hrs from time zero • > 4 units blood • an inability to increase systolic BP by 20 mmHg or to 70 mmHg • and/or an inability to attain a pulse rate <100/min

  28. Failure of therapy • After 6 hrs from time zero • occurrence of haematemesis • ↓systolic BP of > 20 mmHg • ↑pulse rate by 20/min from 6 hr time point • 2 units or more of blood to keep Hb around 9 g/dL

  29. Early rebleeding • > 48 hrs from time zero but within 6 wks • Reasons • Severe initial bleeding • Overly aggressive volume resuscitation • Infection • High hepatic venous pressure gradient • Complications of endoscopic therapy • Renal failure

  30. Late rebleeding • After 6 wks • Reasons • High Child-Pugh score • Large variceal size • Continued alcohol use • Hepatocellular carcinoma

  31. What to do when endoscopic treatment fails • 10 to 20 % of emergencies • No data to support use of higher doses of octreotide or somatostatin • Options • 2nd attempt at endoscopic haemostasis • Balloon tamponade • TIPS • Surgery

  32. BALLOON TAMPONADE Sengstaken-Blakemore tube 250 cc gastric balloon, an esophageal balloon and a gastric suction port Initial control 30 to 90% of patients Major complications – approx 14% Risk of rebleed on deflation Temporary stabilization before more definitive treatment

  33. Sengstaken tube

  34. TIPS Transjugular intrahepatic portosystemic shunt Like side-to-side surgical portacaval shunts without GA or major surgery active bleed + failed endoscopic & medical treatment Poor surgical candidates 60 – 90% 1-month survival vs 10 – 20% in surgery

  35. TIPS

  36. Surgery Ideal surgical patient well preserved liver function who fails emergent endoscopic treatment and has no complications from bleeding or endoscopy Distal splenorenal shunt (Warren shunt) • effective therapy for active variceal haemorrhage in experienced hands

  37. Surgery (contd) Esophageal transection • effective as sclerotherapy • troublesome suture line bleeding • varices recur after variable period of time

  38. Surgery (contd) Sugiura procedure • Controls bleed in 70 – 90% • Entire greater curve, distal 7cms of oesophagus & upper 2/3rds of lesser curve devascularised • Splenectomy not necessary • Oesophageal transection not necessary – already sclero / banded

  39. Gastric varices GLUE (N-butyl-cyanoacrylate, isobutyl-2-cyanoacrylate) or thrombin more effective than sclero or banding TIPS – bleeding control rates > 90% balloon-occluded injection sclerotherapy Surgery

  40. Endoscopic glue

  41. Prediction of patients at risk Varices at OG junction, gastric fundus Higher grade of oeso.varices "red signs“ at endoscopy Higher Child-Pugh score h/o previous variceal bleed Higher variceal pressure (endoscopic gauge)

  42. Prophylaxis against first bleed(Primary Prophylaxis) all cirrhotics – diagnostic endoscopy document varices determine risk of bleed Nonselective β blockers lower portal pressure reduce risk of first bleed Endoscopic banding Intolerance to β blockers Contraindications to β blockers (asthma, renal failure) Higher varix grade

  43. Prevention of rebleed (Secondary Prophylaxis) 70% risk within 1 yr of bleed 70% of all untreated patients die within 1 yr of initial bleed Options endoscopic sclero / band ligation beta blockers and/or oral nitrates TIPS (Child A or B) Surgery (Child A)

  44. Prevention of rebleed (Secondary Prophylaxis) Beta blockers plus band ligation —Combination therapy, better at preventing rebleed TIPS – lesser rebleed, more expensive, more encephalopathy, same survival Surgery – distal splenorenal shunt, better bleeding control but less survival, sclerotherapy better

  45. Prevention of rebleed(Secondary Prophylaxis) Orthotopic Liver transplantation only treatment which corrects portal hypertension and liver failure long wait for an organ Survival  80 to 90% at 1 yr to  60% at 5 yrs

  46. THANKS

  47. Child – Pugh score A – 5 to 6 points B – 7 to 9 C – 10 to 15

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