Variceal Bleeding

Question 1

What is variceal bleeding

Answer 1

Dilated submucosal veins in the lower third of the oesophagus, caused by the anastamosis between the left gastric vein and the esophageal branches of the azygos vein.

Question 2

What are the risk factors for variceal bleeding

Answer 2

1. Child’s score - a (40%, C (85%)
2. Portal system hypertension with hepatic venous pressure gradient of >10mmg
3. Predictor of hemorrhage is size of varices, decompensated cirrhosis and endoscopic stigmata of recent hemorrhage
4. Associated with 20% mortality at 6 weeks

Question 3

When is variceal bleeding suspected in UBGIT

Answer 3

1. Patient history of variceal bleeding
2. History of chronic liver disease
3. Stigmata of chronic liver disease

Question 4

What are the broad categories of management in variceal bleeding?

Answer 4

1. Active variceal bleed
2. Prophylaxis
3. Chronic management

Question 5

How do you stop an active variceal bleed?

Answer 5

1. Reusucitate with ABCDE
Do NOT give an NG tube as it can worsen the bleed
Under-resuscitate as it fluid expansion can worse portal hypertension, only initiate blood transfusion when Hb drops below 7.
Alcohol withdrawal
2. Pharmacological managment
- Antibiotics
- Somatostatin
- Omeprazole
- Vitamin K 
- Terlipressin
- Recombinant factor 7

3. Management for severe bleed with a Sengstaken blakemore tube - temporary management
   - Protect airway first
   - Insert tube endoscopically
   - Confirm with radiology before inflation in stomach
   - Apply weight to exterior of tube (1kg, like 2x 500ml saline) to compress GEJ
   - Can inflate an esophageal balloon if required, but use low pressure of 25-45 to prevent bleeding

Question 6

What is the definitive management for variceal bleed?

Answer 6

Endoscopy - diagnostic and therapeutic

1. Variceal band ligation (1st line) - even better than sclerotherapy
2. Treat with sclerotherapy (inject drugs into varices to constrict them)
   - Induce inflammation and fibrosis
   - Controls bleeding 70% after 1st injection, 85% after 2nd

If there are gastric varices present

• Along the lesser curve, treat as an extension of esophagus
• Along the greater curve, must evaluate splenic vein patency - if patent, manage with endoscopic gastric variceal obturation using N-butyl-cyanoacrylate (clots upon injection). Failure = treat with TIPSS

TIPSS - Transjugular intrahepatic portosystemic shunt
Indicated in protracted bleeding, worsening coagulopathy, visceral hypo-perfusion and refractory ascites
- Radiologically guided intra-hepatic placement of stent between branches of portal and venous system to reduce portal hypertension (eg. right portal vein and right hepatic vein)
- Needle track dilated until pressure gradient of <12mmg is achieved
But it is not a good long term preventive strategy

Question 7

What is the prophylaxis of variceal bleeding?

Answer 7

1. Secondary prophylaxis (after bleed)
   - Band ligation until completely obliterated
   - Non selective beta blockers
2. Primary prophylaxis
   - Prevent variceal bleed for patients who have never bleed
   - Indicated in large varices, medium varices with endoscopic red signs, child C cirrhosis

Treated with non-selective beta blockers (propanolol). Allows for decrease in cardiac output while blocking inducing splachnic vasoconstriction

If contraindicated to beta blockers, treat with long acting nitrates

Question 8

What are the predictors of variceal hemorrhage?

Answer 8

1. Site (GEJ have highest chance of rupture)
2. Size
3. Child’s score
4. Red signs (endoscopic stigmata of recent hemorrhage
5. Previous variceal hemorrhage

Question 9

What are red signs

Answer 9

Endoscopic stigmata of recent hemorrhage

1. Red wale marks (streaks)
2. Cherry red spots (flat spots)
3. Hematocystic spots (blisters)
4. Diffuse erythema

Question 10

What are the size gradings of varices?

Answer 10

▪ Grade 1: Small straight varices not disappearing with insufflation
▪ Grade 2: Enlarged tortuous varices that occupy less than one-third of the lumen
▪ Grade 3: Large varices that occupy more than one-third of the lumen

Question 11

What is the chronic management of varices?

Answer 11

-Start patient on an ablation regimen (endoscopy with initial ligation/sclerotherapy and subsequent endoscopic monitoring and
repeated ligation/sclerotherapy as required to completely ablate varices)
- If patient bleeds again – failed ablation – consider shunt surgery (as above)
- LT propranolol + PPI – Acid suppressive therapy is theorized to improve the stability of clot