Variceal bleeding management

Transjugular intrahepatic portosystemic shunt (TIPS) is a side-to-side non-selective portosystemic shunt that is frequently performed in cirrhosis to manage the complications of portal hypertension, such as variceal bleeding. The observation that the bioavailability of oral midazolam was significantly higher in cirrhotic patients with TIPS than in cirrhotic controls and healthy volunteers [57] may be due to reduced intestinal CYP3A activity or reduced contact with CYP3A in the entero-cyte due to increased splanchnic blood flow [57, 92]. 

Consensus guidelines on the management of osteoporosis associated with chronic liver disease recommend oral calcium and vitamin D supplementation plus transdermal HRT as first-line therapy for women with established osteoporosis. Transdermal oestradiol should be used at a dose of 50 pg/day (equivalent to 2 mg daily of oral oestradiol). This should be given in combination with a progestogen in women with an intact uterus [4]. Oral bisphosphonates should be avoided in cirrhotic patients who may have portal hypertension and oesophageal varices because of their potential to precipitate a variceal bleed [4, 27],... 

J., Tartar, R. Transjugular intrahepatic portosystemic shunt in the management of variceal bleeding indications and clinical results. Surgery 1993 114 719-727... 

Warren, D.W., Henderson, JJVI., Millikan, W.J., Galambos, J.T., Brooks, W.S., Riepe, St.R, Salam, A.S., Kutner, M.H. Distal splenorenal shunt versus endoscopic sclerotherapy for long-term management of variceal bleeding. Preliminary report of a prospective, randomized trial. Ann. Surg. 1986 203 454-462... 

Octreotide is the preferred vasoactive agent employed in the medical management of variceal bleeding. Vasopressin... 

The development of the TIPS provided a major improvement in the management of refractory or severe cases of esophagogastric variceal bleeding and other complications of portal hypertension. The TIPS procedure involves the placement of one or more stents between the hepatic vein and the portal vein (Fig. 37-6). This procedure is widely used because it provides an effective decompressive shunt without laparotomy, and can be employed regardless of Child-Pugh score. Survival rates with TIPS in patients refractory to endoscopic treatment are comparable to rates achieved with portacaval... 

Bleeding esophageal varices Nonoperative management of secreting cutaneous fistulas of the stomach, duodenum, small intestine, or pancreas... 

Vasoactive drug therapy (somatostatin, octreotide, or terlipressin) to stop or slow bleeding is routinely employed early in patient management to allow stabilization of the patient and to permit endoscopy to proceed under more favorable conditions. These agents decrease splanchnic blood flow and reduce portal and variceal pressures, without significant adverse effects. 

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. 

Tripathi D, Eerguson JW, Therapondos G, Plevris JN, Hayes PC. Review article recent advances in the management of bleeding gastric varices. Aliment Pharmacol Ther 2006 24 1-18. 

Although vasopressin and its analogues have been used in the acute management of bleeding esophageal varices, they do not reduce mortality (2,3) and the rate of adverse effects is higher than with octreotide (3). 

Avgerinos A. Approach to the management of bleeding esophageal varices role of somatostatin. Digestion 1998 59(Suppl l) l-22. 

Patients who continue to bleed despite the above measures require surgery (ligation or transection of varices) or placement of a stent between intrahepatic branches of the portal and (systemic) hepatic veins under radiological control. The latter is now the technique of choice for the 10-15% of patients with acute bleeding resistant to conventional treatment, and also for long-term management of patients who are difficult to help by other methods (see below). 

Datta, D., Vlavianos, R, Alisa, A., Westaby, D. Use of fibrin glue (Beriplast) in the management of bleeding gastric varices. Endoscopy 2003 35 675-678... 

Thakeb, F., Salama, Z., Raouf, T.A., Kader, SA., Hamid, H.A. The value of combined use of N-butyl-2-cyanoacrylate and ethanolamine oleate in the management of bleeding oesophagogastric varices. Endoscopy 1995 27 358-364... 

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

The management of varices involves three strategies (a) primary prophylaxis (prevention of the first bleeding episode) (b) treatment of acute variceal hemorrhage and (c) secondary prophylaxis, prevention of rebleeding in patients who have previously bled. °... 

I. V. Infusion The intravenous infusion of vasopressin (Pitressin), the preferred treatment for bleeding from esophageal varices, is at times effective in the management of diffuse gastrointestinal hemorrhage as seen in patients with leukemia and lymphoma. Vasopressin causes vasoconstriction and contraction of the bowel wall smooth muscle. It also has a weak antidiuretic effect. Once the site of bleeding has been identified, an infusion of vasopressin is started at a rate of 0.2 units/min which can be increased in 0.1 unit increments up to 0.6 units/min which is seldom used. This dose can result in intestinal myocardial and/or peripheral vascular ischemic complications. 

Oesophageal varices have traditionally been managed by sclerotherapy. This therapy has proved efficient in controlling active haemorrhage but has no influence on the reduced life expectancy of these patients. The sclerosing agent is injected in repeated 1 to 2-ml aliquots in and around the varicose vein. Sclerotherapy controls the bleeding in up to 90%. 

Lau JYW, Chung SS (2000) Practical management of non-variceal upper gastrointestinal bleeding. In Practice of therapeutic Endoscopy. Eds GNJ Tytgat, M Classen, JD Way and S Nakazawa. 2nd ed., pp 1-11, WB Saunders 2000. 

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