Current Views on Variceal Bleed Management

Current Views on Variceal Bleed Management Dr Sherif Safwat MBchB MRCP
admin December 21, 2011 8:00 am 0 Comments Endoscopy, GI Bleeding, MELD Score, Rockall risk score, Sungestaken tube, Terlipressin, Transjugular intrahepatic portosystemic shunt, ulcer, variceal bleed, variceal ligation, Worse Child-Pugh

Oesophageal Varices
Acute upper GI bleed is a serious condition. Mortality figures have not improved over the last 40 years. The exception is variceal bleed where prognosis has improved despite sicker patients (worse Child-Pugh). Most deaths associated with peptic ulcer bleeding are not direct sequelae of the bleeding ulcer itself. Instead, mortality derives from multi-organ failure, cardiopulmonary conditions, or terminal malignancy.
Obviously patient with acute variceal bleed requires rapid resuscitation, with quick assessment of airways, ensuring good venous access and assessment of vital signs (Pulse and BP) and cross matching of blood. During resuscitation a decision has to be made about endoscopy, whether it is safe to be done with or without anaesthetic support. The decision relies on the level of consciousness of the patient and risk of aspiration.

Cherry Red spot on a varix: assocaited with re-bleeding
I will be discussing the measures to improve survival and the recent advances in treatment.
1) Rapid intervention is critical:
Early scoping and ligation is highly desirable as mortality increases with the increase in number of blood units given
2) Blood transfusion and fluid resuscitation:
Blood volume resuscitation should be undertaken promptly but with caution, aim for hemodynamic stability and a hemoglobin of approximately 8 g/dL. Restitution of all lost blood leads to increases in portal pressure to levels higher than baseline, and to more rebleeding and mortality.
The transfusion of fresh frozen plasma should be considered in patients with significant coagulopathy.

Fresh bleeding from a varix
3) Understanding the Pathogenesis:
It is the rise in the portal pressure measured as Hepatic venous pressure gradient (HVPG) that is predictive of development of oesophageal varices (Normal range 3-5mmHg).
Variceal hemorrhage does not occur when the HVPG is reduced to <12 mmHg or reduced by >20% from base line.
Reduction of HVPG by Terlipressin or octreotide is an important factor in the reduction of mortality with variceal bleed. As well as reducing mortality, it makes the endoscopist’s task easier by making the field of vision less bloody.
Both drugs in the acute stage are effective in lowering portal pressure, but terlipressin is superior as the

Band applied to a varix
lowering of portal pressure is sustained with repeat dosing while with octreotide patients develop tachyphylaxis and despite repeat dosing the portal pressure rises.
Terlipressin recommended dose is 1-2 mg 6hrly.
4) Understand the Risk:
Child-Pugh score, Meld and Rockall risk scoring systems are reliable measures of mortality risk in patients with first variceal bleeding.

Child-Pugh score

1
2
3
Encephalopathy
None
Grade 1-2
Grade 3-4
Ascites
None
Mild-Moderate (diuretic responsive)
Diuretic refractory
Bilirubin (micromol/lit)
<35
35-50
>50
Albumin (gm/l)
35
28-35
<28
Prothrombin (sec prolonged)
<4
4-6
>6
5-6 points: Child A; 7-9 points: Child B; 10-15 points: Child C.
MELD Score = (0.957 * ln(Serum Cr) + 0.378 * ln(Serum Bilirubin) + 1.120 * ln(INR) + 0.643 ) * 10 (if hemodialysis, value for Creatinine is automatically set to 4.0)
In interpreting the MELD Score in hospitalized patients, the 3 month mortality is:
40 or more — 71.3% mortality
30–39 — 52.6% mortality
20–29 — 19.6% mortality
10–19 — 6.0% mortality
<9 — 1.9% mortality
Rockall risk scoring systems
Variable
0
1
2
3
Age
<60
60-79
>80
Shock
No
Pulse>100 BP >100 sys
Sys BP <100
Comorbidity
Nil
CHF, IHD
RF, liver failure, metastatic ca
Diagnosis
Mallory-Weiss
All other diagnosis
GI Malignancy
Evidence of bleeding
None
Blood, adherent clot, spurting vessel
A score less than 3 carries good prognosis but total score more than 8 carries high risk of mortality

Healed ulcers 2 weeks post variceal ligation
5) Recognition of the importance of infection as complication of variceal ligation:
Applying ligation bands to bleeding varices causes bacteraemia which may cause sepsis in the immune-compromised liver failure patient. Antibiotics ( IV ceftriaxone (1 g/day) started within 8 hours of variceal banding improves survival significantly.
6) Variceal ligation technique:
Apply bands as low (distal) as possible (as close as possible to gastro oesophageal junction). Bands above 30 cms are not considered useful. It is worth noting that blood flows upwards (cranial) in an oesophageal varix. Applying a band too high theoretically increases the pressure in the affected vein and could worsen the bleeding.
Number of bands: there is a strong association between the number of bands applied and rate of rebleeding. i.e the more bands you apply the more likely that rebleeding would happen. This is thought to be due to multiple ulcerations at the site of banding. So put as few bands as needed. Do not add this extra band you do not feel is required.
7) Period between Ligation sessions:
After applying bands to a variceal bleed the optimal time for rebanding is 6-8 weeks. Avoid early rebanding (within 2 weeks) as it is associated with increased rebleeding rates.
TIPS (Transjugular intrahepatic portosystemic shunt):
Should be considered in patients with bleeding not controlled by a combination of banding and vasoactive drugs.
9) Gastric varices seen in the cardia should be treated as oesophageal varices with banding:
Gastric varices in the fundus are more difficult to deal with. Glue has been used for treatment. Management will also include vasoactive drugs (Terlipressin) and balloon tamponade. Failure of therapy is an indication for Tips.
10) Sunestaken Tube:
Balloon tamponade can stop bleeding temporally but has high complication rate: aspiration, migration, and necrosis/perforation of the esophagus with mortality rates as high as 20%. It should be only used in ITU setting in an entubated patient.

In Summary:
Resuscitate quickly, do not overtransfuse, aim for Hb 8 gms
Start Terlipressin 2mg 6hrly
Early endoscopy and ligation under appropriate circumstances
Apply bands as low as possible and as few as required, excess bands leads to increased rebleeding risk
Administer 1gm IV cefotaxime daily within 8 hours of ligation
Gastric varices can be ligated if Accessible, fundal varices are more difficult to deal with, either use glue (requires experience) or refer for Tips. Sungestaken tube can be used as a temporary measure
Optimal time for rebanding of varices is 6 weeks


References
1. Factors Predicting Success of Endoscopic Variceal Ligation for Secondary Prophylaxis of Esophageal Variceal Bleeding. Gavin C Harewood; Todd H Baron; Louis M Wong Kee Song. Posted: 03/16/2006; J Gastroenterol Hepatol. 2006;21(1):237-241. © 2006 Blackwell Publishing
2. Improving prognosis following a first variceal haemorrhage over four decades. P.A. McCormick, C O’Keefe
3. Improved survival after variceal hemorrhage over an 11-year period in the Department of Veterans Affairs. El-Serag HB, Everhart JE. Am J Gastroenterol. 2000 Dec;95(12):3566-73.
4. Independent factors associated with recurrent bleeding in cirrhotic patients with esophageal variceal hemorrhage. Lee SW, Lee TY, Chang CS Digestive Diseases and Sciences [2009, 54(5):1128-34]
5. Mortality following blood transfusion for non-variceal upper gastrointestinal bleeding. Ali S Taha, Caroline McCloskey, Theresa Craigen, Wilson J Angerson, Amir A Shah, Christopher G Morran Frontline Gastroenterol 2011;2:218-225 doi:10.1136/fg.2011.004572
6. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Guadalupe Garcia-Tsao, Arun J. Sanyal, Norman D. Grace, William Carey. Article first published online: 24 AUG 2007 DOI: 10.1002/hep.21907 Copyright © 2007 American Association for the Study of Liver Diseases.
About the Author

Dr Sherif Safwat

Dr Sherif Safwat MBchB MRCP (UK)
Consultant Physician and Endoscopist
Broomfield Hospital, Chelmsford UK
Graduated Alexandria University 1981
MRCP (UK) 1988
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