Lecture: Variceal bleeding

Today’s lecture focused on the management of esophageal and gastric varices, from prophylaxis to the acute bleeding episode.  Here are some of the highlights:

– begin prophylaxis only after esophageal varices reach stage II (ie. do not flatten with insufflation)

– beta blockade is as effective as banding ligation for primary prophylaxis; using both is superior for secondary prophylaxis

– beta blockade does not prevent the formation or progression of stage 0/I varices

– for an acute bleeding episode, antibiotics decrease rates of pneumonia/UTI/SBP as well as decrease rates of recurrent bleeding

– octreotide inhibits splanchnic vasodilation, thereby decreasing portal pressures

– volume resuscitation should aim for a Hct of 25, so as not to raise pressures so much that bleeding is prolonged or restarted

– time is not of the essence in variceal bleeding, but early intervention (first 12 hours) is superior to late

– TIPS is considered valuable for early rebleeding (see link below)

– before sending for TIPS, think first about the status of the liver, heart and brain.  are there any relative/absolute contraindications?

And speaking of TIPS for early rebleeding, we discussed the recent NEJM article on this topic.  In the trial, 63 Childs B/C patients were all given octreotide/antibiotics/EGD and then stratified into a medical/EGD arm vs. TIPS arm if they rebled.  Follow up was > 1 year.  Survival was superior for the early TIPS arm.  The study was criticized for being too selective as well as including many alcoholics (that may have had transiently elevated portal pressures from concomitant alcoholic hepatitis).  Nevertheless, this publication has changed the way we approach early rebleeding.  You can click on the link below for the original NEJM manuscript:

NEJM-TIPS for early rebleeding

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