A 45-year-old male with a background of chronic liver disease is admitted to the Emergency Depattment (ED) with massive haematemesis secondary to gastric varices. He is managed with endoscopy and sclerotherapy.
List four other causes for massive haematemesis. (10% marks)
List the clinical indicators for risk of re-bleeding from the gastric varices. (20% marks)
List the pharmacological agents that may reduce the risk of a re-bleed. (20% marks)
Following initial stabilisation and control of bleeding, he deteriorates with a variceal re-bleed.
List the options for controlling the re-bleed AND, where appropriate, the relative advantages and disadvantages of these. (50% marks)
• Gastric or duodenal ulcer with bleeding visible vessel
• Dieulafoy's lesion (large exposed arteriole within gastric wall)
• Tear at gastro-oesophageal junction (Mallory Weiss)
• Aorto-duodenal fistula
• Eroding cancer into vessel (short gastric artery, splenic artery)
b) Rebleed likely if:
• Advanced age
• Unable to band all varices
• Gastric > oesophageal varices
• Severe coagulopathy due to liver disease or massive transfusion
• Severity of portal hypertension or liver disease
• Size of varices – larger higher risk
• Presence of red signs (localised reddish spots on the mucosal surface of the varix)
c) Drugs to reduce risk of re-bleed
• Vasopressin / terlipressin +/- venodilator
• Tranexamic acid
• Oral Sucralfate (local anti-fibrinolytic effect)
• PPI infusion if concomitant ulcer bleeding
• Beta blockers e.g. propranolol if haemodynamics permit
• Short-term prophylactic antibiotics
d) Options for re-bleeding:
• Measure and fix coagulation, ongoing resuscitation
• Repeat endoscopy
o Can be done in ICU although may be more appropriate in the operating theatre
o Requires airway protection
o Allows endoscopic variceal obturation or endoscopic variceal ligation
• TIPS to reduce portal pressure; risks of encephalopathy
o Strategy of choice with initial treatment failure
o May be contra-indicated in high MELD score
o Complications of shunting blood away from liver and increased hepatic encephalopathy
• Balloon tamponade (Sengstaken, Minnesota)
o Only useful in varices in the oesophagus or GO junction; not useful for gastric
o Requires airway protection
o Mucosal injury and necrosis
o Ligation and resection of gastric vessels
o Oesophageal venous ligation
▪ Requires luminal incision; high risk of breakdown in context of liver disease
▪ May not be available depending on local resources
• Balloon-occluded retrograde transverse obliteration (BRTO)
o New technique and still undergoing evaluation
o Increases portal hepatic blood flow and may be alternative for patients who may not tolerate TIPS
o Obliterates spontaneous porto-systemic shunts and may aggravate portal hypertension
• Activated factor 7
o Questionable efficacy
o Highly pro-coagulant
o May have a role in buying time to allow retrieval to a more specialised centre
a) Other causes of haematemesis could include a whole range of differentials. Owing to the author's shameful obsession with structured classifications, this range can be divided into "blood is coming from the gut" and "blood is not coming from the gut but somehow has ended up in the gut". This was generated with the use of Oh's Manual, but contains conditions which are not listed in the canonic Chapter 42 (pp. 487, "Acute gastrointestinal bleeding" by Joseph JY Sung).
Bleeding of gastrointestinal origin
Bleeding of non-gastrointestinal origin
b) The college have listed causes of rebleeding which seem fairly logical, eg. "unable band everything" and "still coagulopathic". To this list, one might also add gastroenterological lazyness (delayed endoscopy increases re-bleeding risk according to Chen et al, 2012). From Augustine et al (2010), there are several features found to be strongly associated with "five-day failure", a composite endpoint consisting of re-bleeding and five-day mortality. All of these have been combined into this list:
c) Pharmacological agents which can decrease the risk of rebleeding:
d) Options for controlling a re-bleed: whenever the college ask for something with a list of advantages and disadvantages, it is usually better to put it in a table. Thus:
Balloon-occluded retrograde transverse obliteration (BRTO)
Factor VIIa is also mentioned by the college in their answer, though they themselves moderate their enthusiasm by pointing out that it has "questionable efficacy". If one reads the papers (eg. Bosch et al, 2008) this would certainly seem correct (there was no effect on any primary endpoints). The mention of this option in the college answer is itself questionable, as it is promoted as an option for controlling a re-bleed even when trial results "do not support the routine use of rFVIIa in this setting". In protest, I did not add it to my table.
Oh's Intensive Care manual: Chapter 42 (pp. 487) Acute gastrointestinal bleeding by Joseph JY Sung
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