Variceal bleeding treatment

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

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... 

Evidence-Based Table of Selected Treatment Recommendations Variceal Bleeding in Portal Hypertension... 

This can be divided into treatment for the complications ascites, neuropsychiatric disease and variceal bleeding and specific treatments for, in particular, copper and iron retention, and for biliary and autoimmune disease. 

Vasopressin and desmopressin are treatments of choice for pituitary diabetes insipidus. The dosage of desmopressin is 10-40 meg (0.1-0.4 mL) in two to three divided doses as a nasal spray or, as an oral tablet, 0.1-0.2 mg two to three times daily. The dosage by injection is 1-4 meg (0.25-1 mL) every 12-24 hours as needed for polyuria, polydipsia, or hypernatremia. Bedtime desmopressin therapy, by intranasal or oral administration, ameliorates nocturnal enuresis by decreasing nocturnal urine production. Vasopressin infusion is effective in some cases of esophageal variceal bleeding and colonic diverticular bleeding. 

Banares R, Albillos A, Rincon D, Alonso S, Gonzalez M, Ruiz-del-Arbol L, Salcedo M, Molinero LM. Endoscopic treatment versus endoscopic plus pharmacologic treatment for acute variceal bleeding a meta-analysis. Hepatology 2002 35(3) 609-15. 

Escorsell A, Ruiz del Arbol L, Planas R, Albillos A, Banares R, Cales P, Pateron D, Bernard B, Vinel JP, Bosch J. Multicenter randomized controlled trial of terlipressin versus sclerotherapy in the treatment of acute variceal bleeding the TEST study. Hepatology 2000 32(3) 471-6. 

Vasopressin and desmopressin are the alternative treatments of choice for pituitary diabetes insipidus. Bedtime desmopressin therapy ameliorates nocturnal enuresis by decreasing nocturnal urine production. Vasopressin infusion is effective in some cases of esophageal variceal bleeding and colonic diverticular bleeding. 

Gusberg, R.X, Peterec, S.M., Sumpio, B.E., Meier, G.H. Splenomegaly and variceal bleeding - hemodynamic basis and treatment implications. Hepato-Gastroenterol. 1994 41 573-577... 

Banares, R., Albillos, A., Rincon, D., Alonso, S., Gonzales, M., Ruiz-del-Arbol, L., Salcedo, M., Molinero, L.-M. Endoscopic treatment versus endoscopic plus pharmacological treatment for acute variceal bleeding. A meta-analysis. Hepatology 2002 35 609-615... 

Bilodeau, M., Rioux, L., Willems, B., Pomier-Layrargues, G. Transjugular intrahepatic portocaval stent shunt as a rescue treatment for life-threatening variceal bleeding in a cirrhotic patient with severe liver failure. Amer. J. Gastroenterol. 1992 87 369-371... 

L., McIntyre, N., Burroughs, A.K. Emergency transjugular intrahepatic portasystemic stent shunting as salvage treatment for uncontrolled variceal bleeding. Brit. J. Surg. 1994 81 1324-1327... 

Step 3 Reduction in portal pressure (42, 74, 113, 115) increased at an early stage, and prevention of variceal bleeding as part of a primary prophylaxis are important measures. In our experience, the development of pulmonary hypertension can be delayed (or even prevented), (s. p. 337) This might be achieved, for example, by administering (5.) molsidomine and (<5.) beta blockers (in combination with spironolactone as in Step 1). The frequent occurrence of portal colopathy (30-40%), even with colitis-like abnormalities, can be reduced by propa-nolol. (21,158) A combination of isosorbide-5-mononi-trate with nadolol has been successful in cases where treatment with beta blockers alone did not prove effective. (s. pp, 258, 355)... 

Variceal bleeding is a frequent and serious event in cirrhosis, and carries an increased risk of death (SEDA-22, 218). Therapy to prevent bleeding is therefore essential in these patients. Propranolol alone has been compared with propranolol plus isosorbide-5-mononitrate in a randomized, double-blind study in 95 patients (21). The combined treatment reduced the incidence of variceal bleeding compared with propranolol alone, but without any improvement in survival Isosorbide-5-mononitrate added to propranolol appeared to be less well tolerated than propranolol alone, since seven patients had to be withdrawn from treatment because of adverse effects (four with feehngs of faintness, two with headache, one with angina-like chest pain), compared with one with atrioventricular block taking propranolol alone. 

Treatment Recommendations Variceal Bleeding-Primary Prophylaxis... 

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... 

Octreotide (Sandostatin) injection is commercially available in the United States for subcutaneous or intravenous administration. A long-acting intramuscular formulation of octreotide (Sandostatin EAR) is also available for monthly administration. In addition to the treatment of acromegaly, octreotide has many other therapeutic uses, including the treatment of carcinoid tumors, vasoactive intestinal peptide tumors (VIPomas), gastrointestinal fistulas, variceal bleeding, diarrheal states, and irritable bowel syndrome. 

P Blockers may be of some value in the treatment of patients undergoing withdrawal from alcohol or those with akathisia. Propranolol and nadolol are efficacious in the primary prevention of variceal bleeding in patients with portal hypertension caused by hepatic cirrhosis. 

Octreotide for IV injection is used in the treatment of acute bleeding from esophageal varices. Variceal bleeding occurs in about half the patients with cirrhosis of the liver and is responsible for about one-third of deaths in these patients. Octreotide is a potent vasoconstrictor that reduces portal and collateral blood flow by constricting visceral vessels, which leads to reduced portal blood pressure and decreases the bleeding. 

The major aims of interventional procedures for portal hypertension are prophylactic and emergent treatment of variceal bleeding, control of hepatic encephalopathy, and treatment of refractory ascites. Hypersplenism associated with hematological disorder is an additional clinical problem in patients with portal hypertension. At present, the main primary embolotherapies available for portal hypertension are balloon-occluded retrograde transvenous obliteration (BRTO) and partial splenic embolization (PSE). In Japan, BRTO has recently been applied for gastric varices instead of either endoscopic treatment or transhepatic intrahepatic portosystemic shunt (TIPS) procedure, and numerous studies have reported that this method has an excellent success rate. Its efficacy for control of hepatic encephalopathy has also been demonstrated. 

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