Skip to main content
SpringerLink
Log in

Management of Acute Variceal Bleeding in Liver Cirrhosis

  • Chapter
  • First Online:
Variceal Bleeding in Liver Cirrhosis

Abstract

Acute variceal bleeding is one of the most fatal complications of cirrhosis and is responsible for about one-third of cirrhosis-related deaths, occurring due to the development of portal hypertension. Variceal bleeding is the most serious complication which occurs in 1/3 of patients with varices and causes 70% of all upper gastrointestinal bleeding episodes in cirrhotic patients. The recommended standard care of acute variceal bleeding is a combined treatment of vasoactive drugs, prophylactic antibiotics, and endoscopic techniques. Many new promising modalities are now developed, including the combination of coil and glue injection for management of bleeding or nonbleeding gastric varices and hemostatic powder application that requires minimal expertise.

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

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 79.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 99.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 109.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Kovalak M, Lake J, Mattek N, Eisen G, Lieberman D, Zaman A. Endoscopic screening for varices in cirrhotic patients: data from a national endoscopic database. Gastrointest Endosc. 2007;65:82–8.

    Article  PubMed  Google Scholar 

  2. Groszmann RJ, Garcia-Tsao G, Bosch J, Grace ND, Burroughs AK, Planas R, et al. Beta-blockers to prevent gastroesophageal varices in patients with cirrhosis. N Engl J Med. 2005;353:2254–61.

    Article  CAS  PubMed  Google Scholar 

  3. Carbonell N, Pauwels A, Serfaty L, Fourdan O, Levy VG, Poupon R. Improved survival after variceal bleeding in patients with cirrhosis over the past two decades. Hepatology. 2004;40(3):652–9.

    Article  PubMed  Google Scholar 

  4. Terés J, Bordas JM, Bru C, Diaz F, Bruguera M, Rodes J. Upper gastrointestinal bleeding in cirrhosis: clinical and endoscopic correlations. Gut. 1976;17:37–40.

    Article  PubMed  PubMed Central  Google Scholar 

  5. D’Amico G. Upper digestive bleeding in cirrhosis. Post-therapeutic outcome and prognostic indicators. Hepatology (Baltimore, MD). 2003;38:599–612.

    Article  Google Scholar 

  6. Yoshida H, Mamada Y, Taniai N, Yoshioka M, Hirakata A, Kawano Y, et al. Risk factors for bleeding esophagogastric varices. J Nippon Med School Nippon Ika Daigaku Zasshi. 2013;80:252–9.

    Article  Google Scholar 

  7. Garcia-Tsao G. Management of acute variceal hemorrhage as a model of individualized care for patients with cirrhosis. Clin Gastroenterol Hepatol. 2018;16:24–6.

    Article  PubMed  Google Scholar 

  8. Romcea A, Tanţău M, Seicean A, Pascu O. Variceal bleeding in cirrhotic patients: risk factors, evolution, treatment. Clujul Medical (1957). 2013;86:107–10.

    Google Scholar 

  9. Tripathi D, Stanley AJ, Hayes PC, Patch D, Millson C, Mehrzad H, et al. U.K. guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut. 2015;64:1680–704.

    Article  PubMed  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

  11. Kravetz D, Bosch J, Arderiu M, Pilar Pizcueta M, Rodés J. Hemodynamic effects of blood volume restitution following a hemorrhage in rats with portal hypertension due to cirrhosis of the liver: influence of the extent of portal-systemic shunting. Hepatology (Baltimore, MD). 1989;9:808–14.

    Article  CAS  Google Scholar 

  12. Ginès P, Fernández J, Durand F, Saliba F. Management of critically-ill cirrhotic patients. J Hepatol. 2012;56:S13–24.

    Article  CAS  PubMed  Google Scholar 

  13. Lightsey JM, Rockey DC. Current concepts in ischemic hepatitis. Curr Opin Gastroenterol. 2017;33:158–63.

    Article  PubMed  Google Scholar 

  14. Goulis J, Patch D, Burroughs AK. Bacterial infection in the pathogenesis of variceal bleeding. Lancet. 1999;353:139–42.

    Article  CAS  PubMed  Google Scholar 

  15. Bernard B, Grangé J-D, Khac EN, Amiot X, Opolon P, Poynard T. Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: a meta-analysis. Hepatology (Baltimore, MD). 1999;29:1655–61.

    Article  CAS  Google Scholar 

  16. Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila F, Soares-Weiser K, Mendez-Sanchez N, Gluud C, et al. Meta-analysis: antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding – an updated Cochrane review. Aliment Pharmacol Ther. 2011;34:509–18.

    Article  CAS  PubMed  Google Scholar 

  17. Fernández J. Bacterial infections in cirrhosis: epidemiological changes with invasive procedures and norfloxacin prophylaxis. Hepatology (Baltimore, MD). 2002;35:140–8.

    Article  Google Scholar 

  18. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology (Baltimore, MD). 2007;46:922–38.

    Article  CAS  Google Scholar 

  19. Bruha R, Marecek Z, Prochazka V, Lata J, Spicak J, Ehrmann J, et al. Double-blind randomized multicenter study comparing the efficacy and safety of 10-day to 5-day terlipressin treatment of bleeding esophageal varices. Hepato-Gastroenterology. 2009;56(90):390–4.

    CAS  PubMed  Google Scholar 

  20. Wells M, Chande N, Adams P, Beaton M, Levstik M, Boyce E, et al. Meta-analysis: vasoactive medications for the management of acute variceal bleeds. Aliment Pharmacol Ther. 2012;35(11):1267–78.

    Article  CAS  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  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;56:819–24.

    Article  CAS  PubMed  Google Scholar 

  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 (Baltimore, MD). 2014;60:954–63.

    Article  CAS  Google Scholar 

  24. Kang SH, Yim HJ, Kim SY, Suh SJ, Hyun JJ, Jung SW, et al. Proton pump inhibitor therapy is associated with reduction of early bleeding risk after prophylactic endoscopic variceal band ligation: a retrospective cohort study. Medicine (Baltimore). 2016;95(8):e2903.

    Article  CAS  Google Scholar 

  25. Barkun AN, Bardou M, Martel M, Gralnek IM, Sung JJ. Prokinetics in acute upper GI bleeding: a meta-analysis. Gastrointest Endosc. 2010;72(6):1138–45.

    Article  PubMed  Google Scholar 

  26. Hsu Y-C, Chen C-C, Wang H-P. Endoscopy timing in acute variceal hemorrhage: perhaps not the sooner the better, but delay not justified. Am J Gastroenterol 2009;104:2629–30; author reply 30-1.

    Google Scholar 

  27. Hsu YC, Chung CS, Tseng CH, et al. Delayed endoscopy as a risk factor for in-hospital mortality in cirrhotic patients with acute variceal hemorrhage. J Gastroenterol Hepatol. 2009;24:1294-9.

    Google Scholar 

  28. Kim YD. Management of acute variceal bleeding. Clin Endosc. 2014;47:308.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Park SW, Cho E, Jun CH, Choi SK, Kim HS, Park CH, et al. Upper gastrointestinal ectopic variceal bleeding treated with various endoscopic modalities. Medicine. 2017;96:e5860.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Riphaus A, Lechowicz I, Frenz MB, Wehrmann T. Propofol sedation for upper gastrointestinal endoscopy in patients with liver cirrhosis as an alternative to midazolam to avoid acute deterioration of minimal encephalopathy: a randomized, controlled study. Scand J Gastroenterol. 2009;44:1244–51.

    Article  CAS  PubMed  Google Scholar 

  31. Baiges A, Hernández-Gea V, Cárdenas A, García-Pagán JC. Portal Hypertensive Bleeding. Clinical Gastrointestinal Endoscopy (Third Edition) 2019:171–9.e3.

    Google Scholar 

  32. Crafford C, Frenckner P. New surgical treatment of varicose veins of the esophagus. Acta Otolaryngol. 1939;27:422–9.

    Article  Google Scholar 

  33. Sarin SK, Nanda R, Sachdev G, Chari S, Anand BS, Broor SL. Intravariceal versus paravariceal sclerotherapy: a prospective, controlled, randomised trial. Gut. 1987;28:657–62.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  34. Al-Busafi SA, Ghali P, Wong P, Deschenes M. Endoscopic management of portal hypertension. Int J Hepatol. 2012;2012:747095.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Baillie J, Yudelman P. Complications of endoscopic sclerotherapy of esophageal varices. Endoscopy. 1992;24:284–91.

    Article  CAS  PubMed  Google Scholar 

  36. Park WG, Yeh RW, Triadafilopoulos G. Injection therapies for variceal bleeding disorders of the GI tract. Gastrointest Endosc. 2008;67:313–23.

    Article  PubMed  Google Scholar 

  37. Stiegmann GV, Goff JS, Sun JH, Davis D, Bozdech J. Endoscopic variceal ligation: an alternative to sclerotherapy. Gastrointest Endosc. 1989;35:431–4.

    Article  CAS  PubMed  Google Scholar 

  38. Pereira-Lima JC, Zanette M, Lopes CV, de Mattos AA. The influence of endoscopic variceal ligation on the portal pressure gradient in cirrhotics. Hepato-Gastroenterology. 2003;50:102–6.

    PubMed  Google Scholar 

  39. Saeed ZA, Stiegmann GV, Ramirez FC, Reveille RM, Goff JS, Hepps KS, et al. Endoscopic variceal ligation is superior to combined ligation and sclerotherapy for esophageal varices: a multicenter prospective randomized trial. Hepatology. 1997;25(1):71–4.

    Article  CAS  PubMed  Google Scholar 

  40. Monici LT, Meirelles-Santos JO, Soares EC, Mesquita MA, Zeitune JM, Montes CG, et al. Microwave coagulation versus sclerotherapy after band ligation to prevent recurrence of high risk of bleeding esophageal varices in Child-Pugh’s A and B patients. J Gastroenterol. 2010;45(2):204–10.

    Article  PubMed  Google Scholar 

  41. Yol S, Belviranli M, Toprak S, Kartal A. Endoscopic clipping versus band ligation in the management of bleeding esophageal varices. Surg Endosc. 2003;17(1):38–42.

    Article  CAS  PubMed  Google Scholar 

  42. Al-Bawardy B, Gorospe EC, Saleem A, Buttar NS, Wong Kee Song LM. Outcomes and predictors of rebleeding after 2-octyl cyanoacrylate injection in acute gastric variceal hemorrhage. J Clin Gastroenterol. 2016;50(6):458–63.

    Article  CAS  PubMed  Google Scholar 

  43. Cheng LF, Wang ZQ, Li CZ, Lin W, Yeo AE, Jin B. Low incidence of complications from endoscopic gastric variceal obturation with butyl cyanoacrylate. Clin Gastroenterol Hepatol. 2010;8(9):760–6.

    Article  CAS  PubMed  Google Scholar 

  44. de Franchis R, Baveno VIF. 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):743–52.

    Article  PubMed  Google Scholar 

  45. Mohan BP, et al. Efficacy and safety of endoscopic ultrasound-guided therapy versus direct endoscopic glue injection therapy for gastric varices: Systematic review and metaanalysis. Endoscopy. 2020;52:259–67.

    Google Scholar 

  46. Avgerinos A, Armonis A. Balloon tamponade technique and efficacy in variceal haemorrhage. Scand J Gastroenterol. 1994;29:11–6.

    Article  Google Scholar 

  47. Sarin SK, Nundy S. Balloon tamponade in the management of bleeding oesophageal varices. Ann R Coll Surg Engl. 1984;66:30–2.

    CAS  PubMed  PubMed Central  Google Scholar 

  48. Khashab M, Kumbhari V, Saxena P. Self-expandable metallic stents for bleeding esophageal varices. Saudi J Gastroenterol. 2013;19:141.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Haq I, Tripathi D. Recent advances in the management of variceal bleeding. Gastroenterol Report. 2017;5:113–26.

    Article  Google Scholar 

  50. Shao X-D, Qi X-S, Guo X-Z. Esophageal stent for refractory variceal bleeding: a systemic review and meta-analysis. Biomed Res Int. 2016;2016:1–10.

    Article  Google Scholar 

  51. McCarty TR, Njei B. Self-expanding metal stents for acute refractory esophageal variceal bleeding: a systematic review and meta-analysis. Dig Endosc. 2016;28:539–47.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Escorsell À, Pavel O, Cárdenas 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 (Baltimore, MD). 2016;63:1957–67.

    Article  Google Scholar 

  53. 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. Hepatology (Baltimore, MD). 2017;65:310–35.

    Article  Google Scholar 

  54. Garcia-Pagan JC, Caca K, Bureau C, Laleman W, Appenrodt B, Luca A, et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med. 2010;362(25):2370–9.

    Article  CAS  PubMed  Google Scholar 

  55. Holster IL, van Beusekom HMM, Kuipers EJ, Leebeek FWG, de Maat MPM, Tjwa ETTL. Effects of a hemostatic powder hemospray on coagulation and clot formation. Endoscopy. 2015;47:638–45.

    Article  PubMed  Google Scholar 

  56. Curcio G, Granata A, Traina M. Hemospray for multifocal bleeding following ultra-low rectal endoscopic submucosal dissection. Digest Endosc. 2014;26:606–7.

    Article  Google Scholar 

  57. Iacucci M. Hemostatic spray – a welcome addition to the armamentarium against gastrointestinal bleeding. Can J Gastroenterol Hepatol. 2014;28:71.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Leblanc S, Vienne A, Dhooge M, Coriat R, Chaussade S, Prat F. Early experience with a novel hemostatic powder used to treat upper GI bleeding related to malignancies or after therapeutic interventions (with videos). Gastrointest Endosc. 2013;78:169–75.

    Article  PubMed  Google Scholar 

  59. Sung J, Luo D, Wu J, Ching J, Chan F, Lau J, et al. Early clinical experience of the safety and effectiveness of Hemospray in achieving hemostasis in patients with acute peptic ulcer bleeding. Endoscopy. 2011;43:291–5.

    Article  CAS  PubMed  Google Scholar 

  60. Tarantino I, Barresi L, Granata A, Curcio G, Traina M. Hemospray for arterial hemorrhage following endoscopic ultrasound-guided pseudocyst drainage. Endoscopy. 2014;46(Suppl 1):E71.

    PubMed  Google Scholar 

  61. Cahyadi O, Bauder M, Meier B, Caca K, Schmidt A. Effectiveness of TC-325 (Hemospray) for treatment of diffuse or refractory upper gastrointestinal bleeding – a single center experience. Endosc Int Open. 2017;05:E1159–E64.

    Article  Google Scholar 

  62. Ibrahim M, El-Mikkawy A, Abdel Hamid M, Abdalla H, Lemmers A, Mostafa I, et al. Early application of haemostatic powder added to standard management for oesophagogastric variceal bleeding: a randomised trial. Gut. 2019;68:844–53.

    Article  CAS  PubMed  Google Scholar 

  63. Smith LA, Stanley AJ, Bergman JJ, Kiesslich R, Hoffman A, Tjwa ET, et al. Hemospray application in nonvariceal upper gastrointestinal bleeding: results of the Survey to Evaluate the Application of Hemospray in the Luminal Tract. J Clin Gastroenterol. 2014;48:e89–92.

    Article  PubMed  Google Scholar 

  64. Yau AHL, Ou G, Galorport C, Amar J, Bressler B, Donnellan F, et al. Safety and efficacy of Hemospray® in upper gastrointestinal bleeding. Can J Gastroenterol Hepatol. 2014;28:72–6.

    Article  PubMed  PubMed Central  Google Scholar 

  65. Ibrahim M, El-Mikkawy A, Abdalla H, Mostafa I, Deviere J. Management of acute variceal bleeding using hemostatic powder. United European Gastroenterol J. 2015;3(3):277–83.

    Article  PubMed  PubMed Central  Google Scholar 

  66. Ibrahim M, El-Mikkawy A, Mostafa I, Devière J. Endoscopic treatment of acute variceal hemorrhage by using hemostatic powder TC-325: a prospective pilot study. Gastrointest Endosc. 2013;78:769–73.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Theodor Bilharz Research Institute, Cairo, Egypt

    Mostafa Ibrahim

  2. ROEYA Gastroenterology and Endoscopy Center, Cairo, Egypt

    Noran Roshdy

Authors
  1. Mostafa Ibrahim
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Noran Roshdy
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Mostafa Ibrahim .

Editor information

Editors and Affiliations

  1. General Hospital of Northern Theater Command, Shenyang, Liaoning, China

    Xiaozhong Guo

  2. General Hospital of Northern Theater Command, Shenyang, Liaoning, China

    Xingshun Qi

Rights and permissions

Reprints and permissions

Copyright information

© 2021 Springer Nature Singapore Pte Ltd.

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Ibrahim, M., Roshdy, N. (2021). Management of Acute Variceal Bleeding in Liver Cirrhosis. In: Guo, X., Qi, X. (eds) Variceal Bleeding in Liver Cirrhosis. Springer, Singapore. https://doi.org/10.1007/978-981-15-7249-4_5

Download citation

  • DOI: https://doi.org/10.1007/978-981-15-7249-4_5

  • Published:

  • Publisher Name: Springer, Singapore

  • Print ISBN: 978-981-15-7248-7

  • Online ISBN: 978-981-15-7249-4

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation