Question 30

College answer

Not available.

Discussion

This question is very similar to Question 1 from the first paper of 2017.

a)    List the clinical indicators for risk of re-bleeding from the gastric varices.

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:

• Uncontrolled bleeding
  • Ongoing acute bleeding, or failure to control bleeding at initial endoscopy ("unable to band all varices")
  • Delay in the procedure
  • Number of bands which were used - according to Xu et al (2011), more than 6 bands is a bad sign
• Severe liver disease
  • Severity of liver disease: Child-Pugh and MELD scores (even their individual components!)
  • A hepatic venous pressure gradient (HVPG) in excess of 20mmHg
  • Aetiology of cirrhosis (apparently some causes are associated with greater risk of rebleeding)
  • Portal vein thrombosis
• Severe initial haemorrhage
  • High transfusion needs
  • Shock state
• Endoscopic features
  • Red Colour Sign - "red wale markings, cherry red or hematocystic spots" (Kleber et al, 1991)
  • Gastric varices, as opposed to oesophageal ones (Park et al, 2015)
• Laboratory features
  • Haematocrit
  • Platelet count
  • Coagulopathy (prolonged PT)

b)    List the pharmacological agents that may reduce the risk of a re-bleed.

• Terlipressin (has been shown to decrease mortality)
• Octreotide ( the next best choice after terlipressin)
• Propanolol (might be helpful but the jury is still out).
• Antibiotics - sepsis promotes the risk of variceal bleeding; literature demonstrates a benefit from antibiotics in this setting (the usual course is 7 days).
• Tranexamic acid - mentioned by the college in their answer to Question 1 from the first paper of 2017, but Tavakoli et al published on this later in 2017 and they did not find any difference in rebleeding rate, nor any other outcome variable for that matter. The whole thing is very 80s. However, as the college answers are definitive, the savvy candidate would need to include this potentially pointless therapy in their answer.
•  Proton pump inhibitors: but PPI infusion probably has no advantage over twice-daily dosing
• Sucralfate is also mentioned by the college in their answer. The "local anti-fibrinolytic effect" is seen more in patients who have had sclerotherapy and then go on to bleed from post-sclerotherapy ulcers (i.e. no longer varices, but still technically a rebleed). This was reported upon by Brooks (1995). The specific benefit seems to be the result of sucralfate counteracting the pro-fibrinolytic effect of ethanolamine oleate, the specific sclerosant agent widely used in the 1990s. 

c)    Briefly discuss the haemoglobin transfusion trigger you will use in the clinical management of this patient   

A haemoglobin transfusion trigger is not usually the way one decides to give a transfusion, as the decision should be based on a series of clinical assessments and weighing the risks andbenefits of blood transfusion. There is not a lot of data to describe numerical transfusion thresholds in this population. One study which could help is Rockey (2014), where the authors reported better outcomes with a transfusion target of 70g/L vs. 90g/L.

d)    List, in order of priority, four specific non-pharmacological options for controlling variceal re-bleed AND, where appropriate, the relative advantages and disadvantages of these.