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)