Variceal bleeding

In patients with bleeding varices, digestion of swallowed blood represents a high protein load this causes nausea and can precipitate symptoms of HE. 

Active bleeding. Acutely bleeding varices can be treated by injection sclerotherapy, by tamponade and by infusion systemically of vasopressin analogues or octreotide (which reduce variceal pressure). Results of controlled trials generally reflect efficacy in oesophageal rather than gastric variceal disease, which form a minority of cases, and can be more difficult to manage. 

Octreotide Sandostatin) is a synthetic somatostatin analogue. It is used in a variety of situations and must be given subcutaneously or intravenously. Most commonly, it is used as a continuous intravenous infusion in patients hospitalized with bleeding varices, because it de-... 

Octreotide Somatostatin analog mechanism not certain May alter portal blood flow and variceal pressures Patients with bleeding varices or at high risk of repeat bleeding Reduced endocrine and exocrine pancreatic activity other endocrine abnormalities GI upset... 

McKee, R.F., Garden, O.J., Carter, D.C. Injection sclerotherapy for bleeding varices risk factors and complications. Brit. J. Surg. 1991 78 1098-1101... 

Orloff, M.X, Orloff, M.S., Rambotti, M., Girard, B. Is portal-systemic shunt worthwhile in Child s class C cirrhosis Long-term results of emergency shunt in 94 patients with bleeding varices. Ann. Surg. 1992 216 256-268... 

Orozco, H., Mercado, M.A., Takahashl, T., Hernandez-Ortiz, X, Cap-ellan, XF., Garcia-Tsao, G. Elective treatment of bleeding varices with the Sugiura operation over 10 years. Amer. J. Surg. 1992 163 585- 589... 

A prospective trial of transjugular intrahepatic portasystemic stent shunt versus small-diameter prosthetic H-graft portacaval shunts in the treatment of bleeding varices. Ann. Surg. 1996 224 378— 386... 

Crotty B, Wood LJ, Willett IR, et al. The management of acutely bleeding varices by injection sclerotherapy. Med J Aust 1986 145 130-133. 

Sanvar SR Vapreotide Esophageal bleeding varices (EVB) SC/IM Clinical trial... 

Melissant CF, Smith SJ, Kazzaz BA, et al. Bleeding varices due to portal hypertension in sarcoidosis. Chest 1993 103 628-629. 

O Portal hypertension is the precipitating factor for the complications of cirrhotic liver disease—ascites, spontaneous bacterial peritonitis (SBP), variceal bleeding, and hepatic encephalopathy. Lowering portal pressure can reduce the complications of cirrhosis and decrease morbidity and mortality. 

Non-selective P-blockers are first-line treatment for preventing variceal bleeding they vasoconstrict the splanchnic bed through multiple mechanisms. 

Cirrhosis is the progressive replacement of normal hepatic cells by fibrous scar tissue. This scarring is accompanied by the loss of viable hepatocytes, which are the functional cells of the liver. Progressive cirrhosis is irreversible and leads to portal hypertension that is in turn responsible for many of the complications of advanced liver disease. These consequences include (but are not limited to) spontaneous bacterial peritonitis (SBP), hepatic encephalopathy, and variceal bleeding.1... 

The splanchnic system drains venous blood from the GI tract to the liver. In portal hypertension there is increased resistance to drainage from the originating organ so collateral vessels (varices) develop in the esophagus, stomach, and rectum to compensate for the increased blood volume. Varices divert blood meant for hepatic circulation back to the systemic circulation this has the unintended deleterious effect of decreasing clearance of medications and potential toxins through loss of first-pass metabolism. Varices are weak superficial vessels, and any additional increase in pressure can cause these vessels to rupture and bleed.15... 

Hemorrhage associated with variceal bleeding may be associated with nausea, vomiting, and hematemesis. Patients may also present with pallor, fatigue, and weakness from blood loss. 

Anemia (decreased hemoglobin and hematocrit) occurs as a result of variceal bleeding, decreased erythrocyte production, and hypersplenism. 

In some cases, cirrhosis is diagnosed incidentally before the patient develops symptoms or acute complications. Other patients may have decompensated cirrhosis at initial presentation they may present with variceal bleeding, ascites, SBP, or HE. Patients may also have some of the laboratory abnormalities and/or signs and symptoms listed above that are associated with cirrhosis.28... 

Balloon tamponade involves the application of direct pressure to the area of bleeding with an inflatable balloon attached to a nasogastric tube. It is an option for patients in whom drug therapy and band ligation fail to stop variceal bleeding. Balloon tamponade is used only when other methods have failed. Once the direct pressure of the balloon is removed, rebleeding often occurs, so balloon tamponade is only a temporary measure prior to more definitive treatment such as shunting.11... 

Non-selective fi-blockers such as propranolol and nadolol are first-line treatments to reduce portal hypertension. This effect reduces bleeding and decreases mortality in patients with known varices. Use of (1-blockers to prevent variceal formation is controversial. 

Only non-selective p-blockers reduce bleeding complications in patients with known varices. Blockade of P, receptors reduces cardiac output and splanchnic blood flow. 02-Adrenergic blockade prevents p2-receptor-mediated splanchnic vasodilation while allowing unopposed a-adrenergic effects this enhances vasoconstriction of both the systemic and splanchnic vascular beds. The combination of P, and P2 effects makes the non-selective p-blockers preferable to car-dioselective agents in treating portal hypertension.1,36,41... 

Initiation of prophylactic antibiotics is recommended during acute variceal bleeding this is typically done with an oral fluoroquinolone (e.g., ciprofloxacin 500 mg twice daily x 7 days) or an IV third-generation cephalosporin. Prophylactic antibiotic therapy reduces in-hospital infections and mortality in patients hospitalized for variceal bleeding.44... 

Patients who have previously experienced spontaneous bacterial peritonitis and have low-protein ascites (ascitic fluid albumin less than 1 g/dL [less than 10 g/L]) are candidates for long-term prophylactic therapy. Recommended regimens include either a single trimethoprim-sulfamethoxazole doublestrength tablet 5 days per week (Monday through Friday) or ciprofloxacin 750 mg once weekly.19,46 Any patient who has experienced an episode of variceal bleeding should also receive prophylactic antibiotics. 

What is the prognosis for this patient who has developed ascites, variceal bleeding, and hepatic encephalopathy within 3 months ... 

Consider antibiotic prophylaxis for SBP in patients with a history of variceal bleeding or prior SBP. 

Chronic hepatitis (disease lasting longer than 6 months) is usually associated with hepatitis B, C, and D. Chronic viral hepatitis may lead to the development of cirrhosis, which may induce end-stage liver disease (ESLD). Complications of ESLD include ascites, edema, jaundice, hepatic encephalopathy, infections, and bleeding esophageal varices. Therefore, prevention and treatment of viral hepatitis may prevent ESLD. 

Variceal bleeding Gastric or esophageal bleeding from collateral vessels (varices). 

Spontaneous bacterial peritonitis (SBP) is a serious complication of cirrhotic ascites, arising most frequently in those with advanced liver disease. Its development leads to a further reduction in the effective arterial blood volume, and it has a mortality rate equivalent to that of a variceal bleed [202], Since hepatic blood flow and func-... 

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