Oesophageal Variceal Bleeding

Related Subjects: | Achalasia | Oesophageal Carcinoma | Diffuse Oesophageal spasm | Diffuse Oesophageal Perforation - Rupture | Gastro-Oesophageal Reflux | Barrett's oesophagus | Upper Gastrointestinal Bleed | Oesophageal Variceal Bleeding | Dieulafoy Lesion | Peptic Ulcer Disease | Oesophagogastroduodenoscopy (OGD/EGD) | Hereditary Haemorrhagic Telangiectasia

Make sure you are immunised to Hepatitis B infection a cause of liver cirrhosis. One needlestick injury is all it may be take to get infected. Endoscopic screening for varices is recommended in those with liver cirrhosis

About

• Seen in those with portal hypertension
• Only a third of all varices bleed
• Bleeding can be massive and mortality is 50%
• Even in those with established liver disease consider other causes - gastritis, peptic ulcer disease, Mallory-Weiss tear

Aetiology

• Endothelin-1 (ET-1) and nitric oxide (NO) are involved
• Portal system carries 1500 ml of blood from gut to liver each minute
• Normal portal pressure < 6 mmHg, varices seen at 10 mmHg and bleed at 12 mmHg

First Bleeding risk increases

• Variceal size, Child-pugh class
• Red markings on the varices such as long, red streaks or red spots

Clinical

• Pallor, Haematemesis, Melaena
• Shocked - hypotensive, tachycardiac, postural hypotension
• Hepatic encephalopathy
• Splenomegaly seen in established portal hypertension
• Blood/Melaena on rectal exam

Investigations

• Group and cross match 6 units
• FBC U&E LFT'S Coagulation screen
• Hepatitis serology

Management

• ABC's and basic resuscitation, Large venflons
• Reverse any coagulopathy, ITU bed
• Ciprofloxacin 500 mg bd for 1 week to reduce risk of bacterial infection
• Lactulose reduces protein load and helps prevent portosystemic encephalopathy
• Sucralfate reduces oesophageal ulceration

Specific therapies

• Endoscopic therapy can stop and control bleeding in 80% of cases. This can be by banding of varices or injection with sclerosant. High-risk markings appearance are those with cherry-red spots, red whale markings and blue varices
• Reduce portal pressures with IV Terlipressin 2 mg IV bolus given 6 hrly . It is an analogue of Vasopressin and causes vasoconstriction of the splanchnic arteries and in this way reduces portal blood flow. Avoid in those with ischaemic heart disease. In these consider Octreotide 50 mcg iv stat followed by 50 mcg per hour which is a less effective alternative.
• Balloon tamponade with a Sengstaken tube can be life-saving. The tube has several balloons. It is placed as one with the distal end in the stomach and distal balloon then inflated and the tube is pulled back putting pressure on the Oesophagogastric junction tamponading the bleeding varices. In some cases, the oesophageal balloon is inflated. Great care is taken. Complication includes aspiration and oesophageal trauma and perforation.
• Transjugular portosystemic shunting (TIPS) - if bleeding continues despite above consider. A stent is placed radiologically and an artificial shunt made between the portal and hepatic veins.

Prophylaxis

• Recurrence is common so a repeated regimen of variceal banding should be followed till all are obliterated
• Oral Propranolol is useful and reduces portal pressures. Compliance and side effects are issues
• TIPS may be considered. Also, consider talking with local Transplantation centre