Acute Variceal Bleeding

Question 1

Acute variceal bleeding cause

Answer 1

Consequence of portal HTN

Question 2

AVB responsible for ___ of cirrhotic related deaths

Answer 2

1/3 (33%)

Question 3

Acute Variceal Bleeding is a risk factor for ____

Answer 3

spontaneous bacterial peritonitis (SBP)

Question 4

Symptoms of acute variceal bleeding

Answer 4

Low BP
High HR (tachycardia)
Hematemesis
Low hbg/hct

Question 5

Treatment for acute variceal bleeding

Answer 5

Supportive care
IV octreotide
Endoscopic variceal ligation (EVL)
SBP prophylaxis
if everything else fails –> TIPS

After bleeding stabilized: beta blockers

Question 6

Acute variceal bleeding supportive care

Answer 6

IV isotonic fluids (NS/LR)
Supplemental O2 PRN
PRBC if hbg <8 (1 unit will increase by 1g/dL)

Question 7

SQ/IM Octreotide is indicated for chemo-induced diarrhea, how does IV Octreotide help in acute variceal bleeding?

Answer 7

Inhibition of glucagon = vasoconstriction of splanchnic vessels

Chemo diarrhea: inhibit motility/hormone secretion (carcinoid tumor)

Question 8

SBP prophylaxis duration

Answer 8

3rd gen cephalosporin
IV ceftriaxone or IV cefotaxime
for 7 days

Question 9

Goal of SBP prophylaxis in acute variceal bleeding

Answer 9

Peritoneum usually sterile, blood pools around GI tract, potential for bacteria transfer into sterile space

Question 10

When do we start nonselective beta-blockers in patients with variceal bleeding?

Answer 10

Start nonselective beta blockers once bleeding has stabilized
- plateau in hgb/hct, HR, BP
- no longer acute bleed
- NOT SEPTIC (hemodynamically unstable)

Propanolol, Nadolol, Carvedilol

Question 11

If IV octreotide and EVL were both unable to control bleeding, what do you do?

Answer 11

Can consider TIPS and bypass the liver completely