Clin Endosc.  2014 Jul;47(4):308-314. 10.5946/ce.2014.47.4.308.

Management of Acute Variceal Bleeding

Affiliations
  • 1Department of Internal Medicine, Chosun University School of Medicine, Gwangju, Korea. giydkim@chosun.ac.kr

Abstract

Acute variceal bleeding could be a fatal complication in patients with liver cirrhosis. In patients with decompensated liver cirrhosis accompanied by ascites or hepatic encephalopathy, acute variceal bleeding is associated with a high mortality rate. Therefore, timely endoscopic hemostasis and prevention of relapse of bleeding are most important. The treatment goals for acute variceal bleeding are to correct hypovolemia; achieve rapid hemostasis; and prevent early rebleeding, complications related to bleeding, and deterioration of liver function. If variceal bleeding is suspected, treatment with vasopressors and antibiotics should be initiated immediately on arrival to the hospital. Furthermore, to obtain hemodynamic stability, the hemoglobin level should be maintained at >8 g/dL, systolic blood pressure >90 to 100 mm Hg, heart rate <100/min, and the central venous pressure from 1 to 5 mm Hg. When the patient becomes hemodynamically stable, hemostasis should be achieved by performing endoscopy as soon as possible. For esophageal variceal bleeding, endoscopic variceal ligation is usually performed, and for gastric variceal bleeding, endoscopic variceal obturation is performed primarily. If it is considered difficult to achieve hemostasis through endoscopy, salvage therapy may be carried out while keeping the patient hemodynamically stable.

Keyword

Acute variceal bleeding; Hemostasis; Endoscopy

MeSH Terms

Anti-Bacterial Agents
Ascites
Blood Pressure
Central Venous Pressure
Endoscopy
Esophageal and Gastric Varices*
Heart Rate
Hemodynamics
Hemorrhage
Hemostasis
Hemostasis, Endoscopic
Hepatic Encephalopathy
Humans
Hypovolemia
Ligation
Liver
Liver Cirrhosis
Mortality
Recurrence
Salvage Therapy
Anti-Bacterial Agents

Figure

  • Fig. 1 Endoscopic variceal ligation of esophageal varices. (A) Endoscopy reveals a red color sign on the esophageal varix through the transparent cap. (B) Variceal ligation is performed by placing the head of the endoscope with a rubber band ligation device over the varix to be ligated, suctioning the varix into the device, and tying the varix by discharging the rubber band.

  • Fig. 2 Endoscopic variceal obturation of gastric varices. (A) Endoscopy reveals spurt bleeding in the gastric varix in the fundus. (B) After puncturing the bleeding varix, the cyanoacrylate and lipiodol mixture is injected. (C) Endoscopic hemostasis is achieved after injection.

  • Fig. 3 Inadequate injection of cyanoacrylate. (A) Spurt bleeding is noted in the slightly protruding gastric varix. (B) Submucosal swelling around the varix is seen after injecting cyanoacrylate.


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Reference

1. Kovalak M, Lake J, Mattek N, Eisen G, Lieberman D, Zaman A. Endoscopic screening for varices in cirrhotic patients: data from a national endoscopic database. Gastrointest Endosc. 2007; 65:82–88. PMID: 17185084.
Article
2. Groszmann RJ, Garcia-Tsao G, Bosch J, et al. Beta-blockers to prevent gastroesophageal varices in patients with cirrhosis. N Engl J Med. 2005; 353:2254–2261. PMID: 16306522.
Article
3. Merli M, Nicolini G, Angeloni S, et al. Incidence and natural history of small esophageal varices in cirrhotic patients. J Hepatol. 2003; 38:266–272. PMID: 12586291.
Article
4. D'Amico G, Pagliaro L, Bosch J. Pharmacological treatment of portal hypertension: an evidence-based approach. Semin Liver Dis. 1999; 19:475–505. PMID: 10643630.
5. North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices. Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. A prospective multicenter study. N Engl J Med. 1988; 319:983–989. PMID: 3262200.
6. Muntaner L, Altamirano JT, Augustin S, et al. High doses of beta-blockers and alcohol abstinence improve long-term rebleeding and mortality in cirrhotic patients after an acute variceal bleeding. Liver Int. 2010; 30:1123–1130. PMID: 20536715.
7. Villanueva C, Piqueras M, Aracil C, et al. A randomized controlled trial comparing ligation and sclerotherapy as emergency endoscopic treatment added to somatostatin in acute variceal bleeding. J Hepatol. 2006; 45:560–567. PMID: 16904224.
Article
8. Abraldes JG, Villanueva C, Bañares R, et al. Hepatic venous pressure gradient and prognosis in patients with acute variceal bleeding treated with pharmacologic and endoscopic therapy. J Hepatol. 2008; 48:229–236. PMID: 18093686.
Article
9. Bosch J, Thabut D, Albillos A, et al. Recombinant factor VIIa for variceal bleeding in patients with advanced cirrhosis: a randomized, controlled trial. Hepatology. 2008; 47:1604–1614. PMID: 18393319.
Article
10. Hepatic venous pressure gradient and prognosis in patients with acute variceal bleeding treated with pharmacologic and endoscopic therapy. Clinical Practice Guideline for Liver Cirrhosis 2005. Seoul: The Korean Association for the Study of the Liver;2005.
11. Sarin SK, Kumar A, Angus PW, et al. Diagnosis and management of acute variceal bleeding: Asian Pacific Association for Study of the Liver recommendations. Hepatol Int. 2011; 5:607–624. PMID: 21484145.
Article
12. The Korean Association for the Study of the Liver. Clinical Practice Guideline for Liver Cirrhosis: Update. Seoul: The Korean Association for the Study of the Liver;2011.
13. Cho SB. Variceal bleeding. Korean J Gastrointest Endosc. 2011; 43(Suppl 2):196–199.
14. Garcia-Tsao G, Bosch J. Management of varices and variceal hemorrhage in cirrhosis. N Engl J Med. 2010; 362:823–832. PMID: 20200386.
Article
15. Burroughs AK, Planas R, Svoboda P. Optimizing emergency care of upper gastrointestinal bleeding in cirrhotic patients. Scand J Gastroenterol Suppl. 1998; 226:14–24. PMID: 9595599.
16. Lebrec D. Pharmacological treatment of portal hypertension: present and future. J Hepatol. 1998; 28:896–907. PMID: 9625326.
Article
17. Fort E, Sautereau D, Silvain C, Ingrand P, Pillegand B, Beauchant M. A randomized trial of terlipressin plus nitroglycerin vs. balloon tamponade in the control of acute variceal hemorrhage. Hepatology. 1990; 11:678–681. PMID: 2109729.
Article
18. Chon CY, Jeong JI, Paik YH, et al. Comparison of somatostatin and vasopressin in the control of acute esophageal variceal hemorrhage: a prospective randomized trial. Korean J Hepatol. 2000; 6:468–473.
19. Lee JH, Lee SH, Koh KC, Paik SW, Rhee JC, Choi KW. Somatostatin vs. balloon tamponade for temporary hemostasis of bleeding esophageal varices before endoscopic variceal ligation. J Hepatol. 1999; 30(Suppl 1):190.
20. Goulis J, Patch D, Burroughs AK. Bacterial infection in the pathogenesis of variceal bleeding. Lancet. 1999; 353:139–142. PMID: 10023916.
Article
21. Bernard B, Grange JD, Khac EN, Amiot X, Opolon P, Poynard T. Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: a meta-analysis. Hepatology. 1999; 29:1655–1661. PMID: 10347104.
Article
22. Rimola A, Garcia-Tsao G, Navasa M, et al. International Ascites Club. Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a consensus document. J Hepatol. 2000; 32:142–153. PMID: 10673079.
Article
23. Fernàndez J, Ruiz del, Gómez C, et al. Norfloxacin vs ceftriaxone in the prophylaxis of infections in patients with advanced cirrhosis and hemorrhage. Gastroenterology. 2006; 131:1049–1056. PMID: 17030175.
Article
24. Cheung J, Soo I, Bastiampillai R, Zhu Q, Ma M. Urgent vs. non-urgent endoscopy in stable acute variceal bleeding. Am J Gastroenterol. 2009; 104:1125–1129. PMID: 19337243.
Article
25. Hsu YC, Chen CC, Wang HP. Endoscopy timing in acute variceal hemorrhage: perhaps not the sooner the better, but delay not justified. Am J Gastroenterol. 2009; 104:2629–2630. PMID: 19806094.
26. de Franchis R. Evolving consensus in portal hypertension. Report of the Baveno IV consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol. 2005; 43:167–176. PMID: 15925423.
Article
27. Kim SH. Variceal bleeding. In : 49th Seminar of Korean Society of Gastrointestinal Endoscopy; 2013 Aug 25; Goyang, Korea. Seoul: Korean Society of Gastrointestinal Endoscopy;2013. p. 46–51.
28. Matsui T. Japanese guideline for gastrointestinal endoscopy: basic concept and control by Post-graduate Education Committee. Korean J Gastrointest Endosc. 2002; 24:349–350.
29. Stiegmann GV, Goff JS, Michaletz-Onody PA, et al. Endoscopic sclerotherapy as compared with endoscopic ligation for bleeding esophageal varices. N Engl J Med. 1992; 326:1527–1532. PMID: 1579136.
Article
30. Jeong SW, Cho JY, Shin SJ, et al. Prevention and management of gastroesophageal variceal hemorrhage. Korean J Gastrointest Endosc. 2010; 40:71–83.
31. Sarin SK, Kumar A. Gastric varices: profile, classification, and management. Am J Gastroenterol. 1989; 84:1244–1249. PMID: 2679046.
32. Shiha G, El-Sayed SS. Gastric variceal ligation: a new technique. Gastrointest Endosc. 1999; 49(4 Pt 1):437–441. PMID: 10202055.
Article
33. Kim T, Shijo H, Kokawa H, et al. Risk factors for hemorrhage from gastric fundal varices. Hepatology. 1997; 25:307–312. PMID: 9021939.
Article
34. Oho K, Iwao T, Sumino M, Toyonaga A, Tanikawa K. Ethanolamine oleate versus butyl cyanoacrylate for bleeding gastric varices: a nonrandomized study. Endoscopy. 1995; 27:349–354. PMID: 7588347.
Article
35. Korula J, Chin K, Ko Y, Yamada S. Demonstration of two distinct subsets of gastric varices. Observations during a seven-year study of endoscopic sclerotherapy. Dig Dis Sci. 1991; 36:303–309. PMID: 1995266.
36. Sarin SK, Jain AK, Jain M, Gupta R. A randomized controlled trial of cyanoacrylate versus alcohol injection in patients with isolated fundic varices. Am J Gastroenterol. 2002; 97:1010–1015. PMID: 12003381.
Article
37. Lo GH, Lai KH, Cheng JS, Chen MH, Chiang HT. A prospective, randomized trial of butyl cyanoacrylate injection versus band ligation in the management of bleeding gastric varices. Hepatology. 2001; 33:1060–1064. PMID: 11343232.
Article
38. Tan PC, Hou MC, Lin HC, et al. A randomized trial of endoscopic treatment of acute gastric variceal hemorrhage: N-butyl-2-cyanoacrylate injection versus band ligation. Hepatology. 2006; 43:690–697. PMID: 16557539.
Article
39. Rengstorff DS, Binmoeller KF. A pilot study of 2-octyl cyanoacrylate injection for treatment of gastric fundal varices in humans. Gastrointest Endosc. 2004; 59:553–558. PMID: 15044898.
Article
40. Soehendra N, Nam VC, Grimm H, Kempeneers I. Endoscopic obliteration of large esophagogastric varices with bucrylate. Endoscopy. 1986; 18:25–26. PMID: 3512261.
Article
41. Seewald S, Mendoza G, Seitz U, Salem O, Soehendra N. Variceal bleeding and portal hypertension: has there been any progress in the last 12 months? Endoscopy. 2003; 35:136–144. PMID: 12561007.
Article
42. Cipolletta L, Bianco MA, Rotondano G, Piscopo R, Prisco A, Garofano ML. Emergency endoscopic ligation of actively bleeding gastric varices with a detachable snare. Gastrointest Endosc. 1998; 47:400–403. PMID: 9609435.
Article
43. Lee MS, Cho JY, Cheon YK, et al. Use of detachable snares and elastic bands for endoscopic control of bleeding from large gastric varices. Gastrointest Endosc. 2002; 56:83–88. PMID: 12085040.
Article
44. Ninoi T, Nishida N, Kaminou T, et al. Balloon-occluded retrograde transvenous obliteration of gastric varices with gastrorenal shunt: long-term follow-up in 78 patients. AJR Am J Roentgenol. 2005; 184:1340–1346. PMID: 15788621.
Article
45. Kim ES, Park SY, Kwon KT, et al. The clinical usefulness of balloon occluded retrograde transvenous obliteration in gastric variceal bleeding. Korean J Hepatol. 2003; 9:315–323.
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