A forty-two (42) year old man has been well, apart from a history of alcohol induced liver dysfunction and portal hypertension. He has abstained from alcohol for the past 8 months after being told that it would kill him. After a large haematemesis he presents drowsy, clinically shocked, with a blood pressure of 80 systolic, heart rate of 124 beats/minute, cold and clammy peripheries. He is also clinically jaundiced.
(b) Variceal bleeding is diagnosed and it initially responds to therapy.
48 hours post admission he remains on invasive respiratory support, with weak withdrawal response to pain despite minimal sedation, a persistent coagulopathy, and is inotrope dependent. Serum bilirubin concentration is elevated (100 micromol/L [N 3-20]).
He develops a further acute variceal bleed associated with hypotension.
Outline your management of this episode.
College Answer
Standard resuscitation goals and technique should be reiterated. Re-bleeding from varices requires repeat endoscopy for diagnosis and treatment. Additional treatments should be considered including vasoconstrictor infusions (eg. somatostatin or vasopressin with GTN), Trans-jugular Intra-hepatic Porto-systemic Shunt (TIPS), and surgical shunts (eg. spleno-renal). Balloon tamponade is being used less frequently because of a high incidence of complications (aspiration, oesophageal rupture, death).
Ongoing investigation and treatment of coagulopathy, and investigation of causes of jaundice should be undertaken. Treatment should include strategies to minimise hepatic encephalopathy.
Discussion
A systematic approach should be taken. I will not repeat the ABCs. Of course, one would ensure satisfactory maintenance of oxygenation and normotension. Certainly, one would replace the missing factors by transfusing blood products, as well as actual packed cells, and vitamin K.
Straight to the specific management:
- Hemostasis:
- Re-bleeding from varices requires re-endoscopy. Sclerotherapy and/or banding would be the ideal way of managing this bleed, as it would have the fewest complications.
- A Sengstaken-Blakemore tube is an option, but even when it was popular the experienced users noted that optimal pharmacological therapy is better than inexperienced use of balloon tamponade
- Reducing portal hypertension pharmacologically
- Terlipressin is the drug of choice in decreasing portal venous congestion, and it has beenshown to decrease mortality in variceal bleeding
- Octreotide is the next best choice
- Non-selective beta blockade might be helpful to prevent further re-bleeding, but the jury is still out.
- Reducing portal hypertension invasively
- TIPS decreases the chances of treatment failure in refractory variceal bleeding (in one study, the probability of remaining bleed-free was 97% in the TIPS group and 50% in the pharmacotherapy group)
References
Garcia-Tsao, Guadalupe, and Jaime Bosch. "Management of varices and variceal hemorrhage in cirrhosis." New England Journal of Medicine 362.9 (2010): 823-832.
García-Pagán, Juan Carlos, et al. "Early use of TIPS in patients with cirrhosis and variceal bleeding." New England Journal of Medicine 362.25 (2010): 2370-2379.
Vlavianos, P., et al. "Balloon tamponade in variceal bleeding: use and misuse."BMJ: British Medical Journal 298.6681 (1989): 1158.
Reverter, Enric, and Juan Carlos García‐Pagán. "Management of an acute variceal bleeding episode." Clinical Liver Disease 1.5 (2012): 151-154.
Ioannou, G. N., J. Doust, and D. C. Rockey. "Terlipressin in acute oesophageal variceal haemorrhage." Alimentary pharmacology & therapeutics 17.1 (2003): 53-64.
Corley, Douglas A., et al. "Octreotide for acute esophageal variceal bleeding: a meta-analysis." Gastroenterology 120.4 (2001): 946-954.
Reiberger, Thomas, et al. "Carvedilol for primary prophylaxis of variceal bleeding in cirrhotic patients with haemodynamic non-response to propranolol." Gut62.11 (2013): 1634-1641.