Variceal bleeds

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... 

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... 

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. 

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-... 

The Child-Pugh classification system uses a combination of physical and laboratory findings to assess and define the severity of cirrhosis and is a predictor of patient survival, surgical outcome, and risk of variceal bleeding (Table 21-3). 

Clinical improvement or resolution of acute complications, such as variceal bleeding, and resolution of hemodynamic instability for an episode of acute variceal hemorrhage. 

Assess the risk for variceal bleeding and begin pharmacologic prophylaxis where indicated, reserving endoscopic therapy for high-risk patients or acute bleeding episodes. 

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

EBL is the recommended form of endoscopic therapy for acute variceal bleeding, although endoscopic injection sclerotherapy (injection of 1 to 4 mL of a sclerosing agent into the lumen of the varices) may be used if the ligation is technically difficult. EBL is often used for upper GI tract hemorrhage secondary to portal hypertension and varices. 

Variceal bleeding Pharmacologic prophylaxis fever, anorexia, malaise, fatigue) Child-Pugh score, Appropriate reduction in... 

Decompensated liver disease is complicated by jaundice, refractory ascites, bacterial peritonitis, coagulopathy, and variceal bleeding and may require liver transplantation. The number of liver transplants for decompensated cirrhosis doubled from 1990 to 2004, when 5845 cadaveric (orthotopic) liver transplants were performed (65). 

Variceal bleeding 50 trxg IV over 5-10 min, then 50 trxg/hr IV infusbn ... 

Acute fresh bleeding from the upper gastrointestinal tract is a mandatory cause of hospital referral. About half of all cases are due to peptic ulceration, and variceal bleeding accounts for a varying, but generally minor component of the remainder depending on the frequency of alcoholic cirrhosis or of hepatitis B-induced cirrhosis in the population. 

Diagnosis is established by a combination of clinical examination (variceal bleeding is unlikely in the absence of stigmata of liver disease) and endoscopy. Bleeding ulcers may then be recognised as actively bleeding, or though the presence of a black base to the ulcer with, occasionally a visible vessel. 

Variceal bleeding. Almost all studies of pharmacotherapy have been small and in consequence metaanalyses depend upon the aggregation of patients from multiple sets where comparability cannot be assured. 

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. 

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