Skip to main content
SpringerLink
Log in

Acute variceal bleeding: risk stratification and management (including TIPS)

  • Special Issue - Portal Hypertension
  • Published:
Hepatology International Aims and scope Submit manuscript

Abstract

Acute variceal bleeding should be suspected in all patients with cirrhosis presenting with upper gastrointestinal bleeding. Vasoactive drugs and prophylactic antibiotics must be started as soon as possible, even before performing the diagnostic endoscopy. Once the patient is hemodynamically stable, upper gastrointestinal endoscopy should be performed in order to confirm the diagnosis and provide endoscopic therapy (preferably banding ligation). After this initial approach, the most appropriate therapy to prevent both early and late rebleeding must be instituted following a risk stratification strategy. The present chapter will focus on the initial management of patients with acute variceal bleeding, including general management and hemostatic therapies, as well as the available treatments in case of failure to control bleeding or development of rebleeding.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. D’Amico G, De Franchis R, Cooperative Study Group. Upper digestive bleeding in cirrhosis. Post-therapeutic outcome and prognostic indicators. Hepatology 2003;38(3):599–612

  2. Franchis R De, Baveno V. Expanding consensus in portal hypertension. Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol 2015;63(3):743–752 (European Association for the Study of the Liver)

  3. Bosch J, Abraldes J, Berzigotti A, García-Pagán J. Portal hypertension and gastrointestinal bleeding. Semin Liver Dis 2008;28:3–25

  4. Villanueva C, Colomo A, Bosch A, Concepcion M, Hernandez-Gea V, Aracil C, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med 2013;368:11–21

  5. Ginès P, Fernández J, Durand F, Saliba F. Management of critically-ill cirrhotic patients. J Hepatol 2012;56(Sppl 1) S13-24

  6. Lightsey JM, Rockey DC. Current concepts in ischemic hepatitis. Curr Opin Gastroenterol 2017;33:1

  7. Tripodi A, Primignani M, Chantarangkul V, Dell’Era A, Clerici M, de Franchis R, et al. An imbalance of pro- vs anti-coagulation factors in plasma from patients with cirrhosis. Gastroenterology 2009;137(6):2105–2111 (Elsevier Inc)

  8. Lisman T, Caldwell SH, Burroughs AK, Northup PG, Senzolo M, Stravitz RT, et al. Hemostasis and thrombosis in patients with liver disease: the ups and downs. J Hepatol 2010;53(2):362–371 (European Association for the Study of the Liver)

  9. Grace N, Groszmann R, García-Tsao G, Burroughs A, Pagliaro L, Makuch R, et al. Portal hypertension and variceal bleeding: an AASLD single topic symposium. Hepatology 1998;28(3):868–880

  10. Bosch J, Thabut D, Bendtsen F, D’Amico G, Albillos A, González-Abraldes J, et al. Recombinant factor VIIa for upper gastrointestinal bleeding in patients with cirrhosis: a randomized, double-blind trial. Gastroenterology 2004;127(4):1123–1130

  11. Bosch J, Thabut D, Albillos A, Carbonnel N, Spicak J, Massard J, et al. Recombinant factor VIIa for variceal bleeding in patients with advanced cirrhosis: a randomized, controlled trial. Hepatology 2008;47(5):1604–1614

  12. Lentschener C, Flaujac C, Ibrahim F, Gouin-Thibault I, Bazin M, Sogni P, et al. Assessment of haemostasis in patients with cirrhosis: Relevance of the ROTEM tests? Eur J Anaesthesiol 2016;33:126–133

  13. Levacher S, Letoumelin P, Pateron D, Blaise M, Lapandry C, Pourriat J. Early administration of terlipressin plus glyceryl trinitrate to control active upper gastrointestinal bleeding in cirrhotic patients. Lancet 1995;346(8979):865–868

  14. Ioannou G, Doust J, Rockey D. Systematic review: terlipressin in acute oesophageal variceal haemorrhage. Aliment Pharmacol Ther 2003;17(1):53–64

  15. Solà E, Lens S, Guevara M, Martín-Llahí M, Fagundes C, Pereira G, et al. Hyponatremia in patients treated with terlipressin for severe gastrointestinal bleeding due to portal hypertension. Hepatology 2010;52(5):1783–1790

  16. Avgerinos A, Nevens F, Raptis S, Fevery J. Early administration of somatostatin and efficacy of sclerotherapy in acute oesophageal variceal bleeds: the European Acute Bleeding Oesophageal Variceal Episodes (ABOVE) randomised trial. Lancet 1997;22(350):1495–1499

  17. González-Abraldes J, Bosch J. Somatostatin and analogues in portal hypertension. Hepatology 2002;35(6):1305–1312

  18. Villanueva C, Planella M, Aracil C, López-Balaguer JM, González B, Miñana J, et al. Hemodynamic effects of terlipressin and high somatostatin dose during acute variceal bleeding in nonresponders to the usual somatostatin dose. Am J Gastroenterol 2005;100(3):624–630

  19. Moitinho E, Planas R, Bañares R, Albillos A, Ruiz-del-Arbol L, Gálvez C, et al. Multicenter randomized controlled trial comparing different schedules of somatostatin in the treatment of acute variceal bleeding. J Hepatol 2001;35(6):712–718

  20. Bañares R, Albillos A, Rincón D, Alonso S, González M, Ruiz-del-Arbol L, et al. Endoscopic treatment versus endoscopic plus pharmacologic treatment for acute variceal bleeding: a meta-analysis. Hepatology 2002;35(3):609–615

  21. D’Amico G, Pagliaro L, Bosch J. Pharmacological treatment of portal hypertension: an evidence-based approach. Semin Liver Dis 1999;19:475–505

  22. Azam Z, Hamid S, Jafri W, Salih M, Abbas Z, Abid S, et al. Short course adjuvant terlipressin in acute variceal bleeding: a randomized double blind dummy controlled trial. J Hepatol 2012;56(4):819–824

  23. Seo YS, Park SY, Kim MY, Kim JH, Park JY, Yim HJ, et al. Lack of difference among terlipressin, somatostatin, and octreotide in the control of acute gastroesophageal variceal hemorrhage. Hepatology 2014;60(3):954–963

  24. Lo G, Lai K, Cheng J, Lin C, Huang J, Hsu P, et al. Emergency banding ligation versus sclerotherapy for the control of active bleeding from esophageal varices. Hepatology 1997;25(5):1101–1104

  25. Haddara S, Jacques J, Lecleire S, Branche J, Leblanc S, Le Baleur Y, et al. A novel hemostatic powder for upper gastrointestinal bleeding: a multicenter study (the GRAPHE registry). Endoscopy 2016;48(12):1084–1095

  26. Hagel AF, Albrecht H, Nägel A, Vitali F, Vetter M, Dauth C, et al. The application of hemospray in gastrointestinal bleeding during emergency endoscopy. Gastroenterol Res Pract 2017;2017:6–8

  27. Ibrahim M, El-Mikkawy A, Abdalla H, Mostafa I, Devière J. Management of acute variceal bleeding using hemostatic powder. United Eur Gastroenterol J 2015;3(3):277–283

  28. Ibrahim M, Lemmers A, Devière J. Novel application of Hemospray to achieve hemostasis in post-variceal banding esophageal ulcers that are actively bleeding. Endoscopy 2014;46(SUPPL 1):263

  29. Sarin S, Lahoti D, Saxena S, Murthy N, Makwana U. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology 1992;16(6):1343–1349

  30. Oho K, Iwao T, Sumino M, Toyonaga A, Tanikawa K. Ethanolamine oleate versus butyl cyanoacrylate for bleeding gastric varices: a nonrandomized study. Endoscopy 1995;27(5):349–354

  31. Tan PC, Hou MC, Lin HC, Liu T Te, Lee FY, Chang FY, et al. A randomized trial of endoscopic treatment of acute gastric variceal hemorrhage: N-butyl-2-cyanoacrylate injection versus band ligation. Hepatology 2006;43(4):690–697

  32. Garcia-Pagán JC, Barrufet M, Cardenas A, Escorsell À. Management of gastric varices. Clin Gastroenterol Hepatol 2014;12(6):919.e1–928.e1 (Elsevier, Inc)

  33. Lo GH, Lai KH, Cheng JS, Chen MH, Chiang HT. A prospective, randomized trial of butyl cyanoacrylate injection versus band ligation in the management of bleeding gastric varices. Hepatology 2001;33(5):1060–1064

  34. Gubler C, Baruerfeind P. Safe and successful endoscopic initial treatment and long-term eradication of gastric varices by endoscopic ultrasound-guided histoacryl (N-butyl-2-cyanocrylate) injection. Scand J Gastroenterol 2014;49:1136–1142

  35. Iwase H, Suga S, Morise K. Color Doppler endoscopic ultrasonography for the evaluation of gastric varices and endoscopic obliteration with cyanoacrylate glue. Gastrointest Endosc 1995;41:150–154

  36. Lo G, Liang H, Chen W, Lai K, Hsu P, Lin C, et al. A prospective, randomized controlled trial of transjugular intrahepatic portosystemic shunt versus cyanoacrylate injection in the prevention of gastric variceal rebleeding. Endoscopy 2007;39:679–685

  37. Wang YB, Zhang JY, Gong JP, Zhang F, Zhao Y. Balloon-occluded retrograde transvenous obliteration versus transjugular intrahepatic portosystemic shunt for treatment of gastric varices due to portal hypertension: A meta-analysis. J Gastroenterol Hepatol 2016;31(4):727–733

  38. Thalheimer U, Triantos C, Samonakis D, Patch D, Burroughs A. Infection, coagulation and variceal bleeding in cirrhosis. Gut 2005;54(4):556–563

  39. Bernard B, Grangé J, Khac E, Amiot X, Opolon P, Poynard T. Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: a meta-analysis. Hepatology 1999;29(6):1655–1661

  40. Hou M, Lin H, Liu T, Kuo B, Lee F, Chang F, et al. Antibiotic prophylaxis after endoscopic therapy prevents rebleeding in acute variceal hemorrhage: a randomized trial. Hepatology 2004;39(3):746–753

  41. Olson JC, Saeian K. Gastrointestinal issues in liver disease. Crit Care Clin 2016;32(3):371–384 (Elsevier Inc)

  42. Fernández J, Ruiz del Arbol L, Gómez C, Durandez R, Serradilla R, Guarner C, et al. Norfloxacin vs ceftriaxone in the prophylaxis of infections in patients with advanced cirrhosis and hemorrhage. Gastroenterology 2006;131(4):1049–1056

  43. Riggio O, Varriale M, Testore G, Di Rosa R, Di Rosa E, Merli M, et al. Effect of lactitol and lactulose administration on the fecal flora in cirrhotic patients. J Clin Gastroenterol 1990;12(4):433–436

  44. Vilstrup H, Amodio P, Bajaj J, Cordoba J, Ferenci P, Mullen K, et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Hepatology 2014;60(2):715–735

  45. Sharma P, Agrawal A, Sharma BC, Sarin SK. Prophylaxis of hepatic encephalopathy in acute variceal bleed: A randomized controlled trial of lactulose versus no lactulose. J Gastroenterol Hepatol 2011;26(6):996–1003

  46. Bass N, Mullen K, Sanyal A, Poordad F, Neff G, Leevy C, Sigal S, et al. Rifaximin treatment in hepatic encephalopathy. N Engl J Med 2010;362(12):1070–1081

  47. Cardenas A, Ginès P, Uriz J, Bessa X, Salmerón J, Mas A, et al. Renal failure after upper gastrointestinal bleeding in cirrhosis: incidence, clinical course, predictive factors and short-term prognosis. Hepatology 2001;31(4):617–676

  48. Escorsell A, Ginès A, Llach J, García-Pagán J, Bordas J, Bosch J, et al. Increasing intra-abdominal pressure increases pressure, volume and wall tension in esophageal varices. Hepatology 2002;36:936–940

  49. Kravetz D, Bildozola M, Argonz J, Romero G, Korula J, Muñoz A, et al. Patients with ascites have higher variceal pressure and wall tension than patients without ascites. Am J Gastroenterol 2000;95(7):1770–1775

  50. García-Pagán J, Salmerón J, Feu F, Luca A, Ginès P, Pizcueta P, et al. Effects of low-sodium diet and spironolactone on portal pressure in patients with compensated cirrhosis. Hepatology 1994;19(5):1095–1099

  51. Kravetz D, Romero G, Argonz J, Guevara M, Suarez a, Abecasis R, et al. Total volume paracentesis decreases variceal pressure, size, and variceal wall tension in cirrhotic patients. Hepatology 1997;25(1):59–62

  52. Escorsell A, Bandi J, Andreu V, Moitinho E, García-Pagán J, Bosch J, et al. Desensitization to the effects of intravenous octreotide in cirrhotic patients with portal hypertension. Gastroenterology 2001;120(1):161–169

  53. Abraldes J, Angermayr B, Bosch J. The management of portal hypertension. Clin Liver Dis 2005;9(4):685–713

  54. La Mura V, Nicolini A, Tosetti G, Primignani M. Cirrhosis and portal hypertension: the importance of risk stratification, the role of hepatic venous pressure gradient measurement. World J Hepatol 2015;7(4):688–695

  55. Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 Practice Guidance by the American Association for the Study of Liver Diseases. 2017;65(1):310–335

  56. Moitinho E, Escorsell A, Bandi J, Salmerón J, García-Pagán J, Rodés J, et al. Prognostic value of early measurements of portal pressure in acute variceal bleeding. Gastroenterology 1999;117(3):626–631

  57. Villanueva C, Ortiz J, Minana J, Soriano G, Sabat M, Boadas J, et al. Somatostatin treatment and risk stratification by continuous portal pressure monitoring during acute variceal bleeding. Gastroenterology 2001;121:110–117

  58. Monescillo A, Martínez-Lagares F, Ruiz-del-Arbol L, Sierra A, Guevara C, Jimenez E, et al. Influence of portal hypertension and its early decompression by TIPS placement on the outcome of variceal bleeding. Hepatology 2004;40:793–801

  59. Lecleire S, Di Fiore F, Merle V, Herve S, Duhamel C, Rudelli A, et al. Acute upper gastrointestinal bleeding in patients with liver cirrhosis and in non-cirrhotic patients: epidemiology and predictive factors of mortality in a prospective multicenter population-based study. J Clin Gastroenterol 2005;39(4):321–327

  60. Thomopoulos K, Theocharis G, Mimidis K, Lampropoulou-Kratza C, Alexandridis E, Nikolopoulou V. Improved survival of patients presenting with acute variceal bleeding. Prognostic indicators of short and long term mortality. Dig Liver Dis 2006;38:899–904

  61. Bambha K, Kim WR, Pedersen RA, Bida JP, Kremers WK, Kamath P. Predictors of rebleeding and mortality following acute variceal hemorrhage in patients with cirrhosis. Gut 2008;57:814–820

  62. Reverter E, Tandon P, Augustin S, Turon F, Casu S, Bastiampillai R, et al. A MELD-based model to determine risk of mortality among patients with acute variceal bleeding. Gastroenterology 2014;146(2):412.e3–419.e3 (Elsevier, Inc.)

  63. Abraldes JG, Villanueva C, Bañares R, Aracil C, Catalina MV, García-Pagán JC, et al. Hepatic venous pressure gradient and prognosis in patients with acute variceal bleeding treated with pharmacologic and endoscopic therapy. J Hepatol 2008;48(2):229–236

  64. Villanueva C, Planella M, Aracil C, López-Balaguer J, González B, Miñana J, et al. Hemodynamics effects of terlipressin and high somatostatin dose during acute variceal bleeding in nonresponders to the usual somatostatin dose. Am J Gastroenterol 2005;100(3):624–630

  65. D’Amico G, Garcia-Pagan JC, Luca A, Bosch J. Hepatic vein pressure gradient reduction and prevention of variceal bleeding in cirrhosis: a systematic review. Gastroenterology 2006;131(5):1611–1624

  66. Avgerinos A, Armonis A, Stefanidis G, Mathou N, Vlachogiannakos J, Kougioumtzian A, et al. Sustained rise of portal pressure after sclerotherapy, but not band ligation, in acute variceal bleeding in cirrhosis. Hepatology 2004;39(6):1623–1630

  67. D’Amico G, Pietrosi G, Tarantino I, Pagliaro L. Emergency sclerotherapy versus vasoactive drugs for variceal bleeding in cirrhosis: a Cochrane meta-analysis. Gastroenterology 2003;124(5):1277–1291

  68. García-Pagán JC, Caca K, Bureau C, Laleman W, Appenrodt B, Luca A, et al. Early use of TIPS in patients with cirrhosis and variceal bleeding for the early TIPS (transjugular intrahepatic portosystemic shunt) cooperative study group. N Engl J Med 2010;362:2370–2379

  69. Garcia-Pagán JC, Di Pascoli M, Caca K, Laleman W, Bureau C, Appenrodt B, et al. Use of early-TIPS for high-risk variceal bleeding: Results of a post-RCT surveillance study. J Hepatol 2013;58(1):45–50

  70. Chau T, Patch D, Chan Y, Nagral A, Dick R, Burroughs A. “Salvage” transjugular intrahepatic portosystemic shunts: gastric fundal compared with esophageal variceal bleeding. Gastroenterology 1998;114(5):981–987

  71. Garcia-Tsao G, Sanyal A, Grace N, Carey W, Practice Guidelines Committee of American Association for Study of Liver Diseases, Practice Parameters Committee of American College of Gastroenterology. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Am J Gastroenterol 2007;102(9):2086–2102

  72. D’Amico M, Berzigotti A, Garcia-Pagan J. Refractory acute variceal bleeding: what to do next? Clin Liver Dis 2010;14(2):297–305

  73. Terés J, Cecilia A, Bordas J, Rimola A, Bru C, Rodés J. Esophageal tamponade for bleeding varices. Controlled trial between the Sengstaken-Blakemore tube and the Linton-Nachlas tube. Gastroenterology 1978;75(4):566–569

  74. Escorsell A, Pavel O, Cardenas A, Morillas R, Llop E, Villanueva C, et al. Esophageal balloon tamponade versus esophageal stent in controlling acute refractory variceal bleeding: a multicenter randomized, controlled trial. Hepatology 2016;63(6):1957–1967

  75. Saad W. Balloon-occluded retrograde transvenous obliteration of gastric varices: concept, basic techniques, and outcomes. Semin Intervent Radiol 2012;29(2):118–128

  76. Fukuda T, Hirota S, Sugimura K. Long-term results of balloon-occluded retrograde transvenous obliteration for the treatment of gastric varices and hepatic encephalopathy. J Vasc Interv Radiol 2001;12(3):327–336

Download references

Author information

Authors and Affiliations

  1. Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain

    Virginia Hernández-Gea, Claudia Berbel, Anna Baiges & Juan C. García-Pagán

  2. Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, IDIBAPS, University of Barcelona, C/Villarroel, 170, 08036, Barcelona, Spain

    Virginia Hernández-Gea, Anna Baiges & Juan C. García-Pagán

Authors
  1. Virginia Hernández-Gea
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Claudia Berbel
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Anna Baiges
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Juan C. García-Pagán
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Juan C. García-Pagán.

Ethics declarations

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Funding

Virgínia Hernández-Gea received support in part by grants from the Ministerio de Educación y Ciencia (PI14/00182).

Conflict of interest

Virgínia Hernández-Gea declares that she has no conflict of interest. Claudia Berbel declares that she has no conflict of interest. Anna Baiges declares that she has no conflict of interest. Juan Carlos García-Pagán declares that he has no conflict of interest. Virgínia Hernández-Gea received support in part by grants from the Ministerio de Educación y Ciencia (PI14/00182). Juan Carlos García-Pagán received support in part by grants from Ministerio de Educación y Ciencia (SAF-2016-75767-R and PIE 15/00027) and received speaker fees from Gore and research grants from Novartis and Exalenz.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hernández-Gea, V., Berbel, C., Baiges, A. et al. Acute variceal bleeding: risk stratification and management (including TIPS). Hepatol Int 12 (Suppl 1), 81–90 (2018). https://doi.org/10.1007/s12072-017-9804-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12072-017-9804-3

Keywords

Search

Navigation