Variceal Hemorrhage

  • Elizabeth A. BelloliEmail author
  • Steven E. Gay


Acute variceal hemorrhage is one of the most common reasons for intensive care unit admission of patients with cirrhosis, with mortality rates improved in recent years to 15–20%. Patients with variceal bleeding require immediate and aggressive resuscitation, with the goals of maintaining end-organ perfusion and achieving hemostasis as soon as possible. The critical care practitioner must be familiar with recommended medications and transfusion parameters, and indications for more invasive procedures should endoscopic measures fail to halt bleeding. Complications such as infection and hepatic encephalopathy should be given attention. In this chapter, we discuss typical management of a patient with suspected variceal bleeding and more controversial aspects in their care.


Varices Bleeding Cirrhosis Vasoconstrictors Resuscitation Intubation Coagulopathy Surgery TIPS BRTO 


  1. 1.
    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. 2017;65(1):310–35.CrossRefGoogle Scholar
  2. 2.
    British Committee for Standards in Haematology, Stainsby D, MacLennan S, Thomas D, Isaac J, Hamilton PJ. Guidelines on the management of massive blood loss. Br J Haematol. 2006;135(5):634–41.CrossRefGoogle Scholar
  3. 3.
    Waters JH. Role of the massive transfusion protocol in the management of haemorrhagic shock. Br J Anaesth. 2014;113(Suppl 2):ii3–8.CrossRefGoogle Scholar
  4. 4.
    Cosgriff N, Moore EE, Sauaia A, Kenny-Moynihan M, Burch JM, Galloway B. Predicting life-threatening coagulopathy in the massively transfused trauma patient: hypothermia and acidoses revisited. J Trauma. 1997;42(5):857–61. discussion 61-2CrossRefGoogle Scholar
  5. 5.
    Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W, Practice Guidelines Committee of the American Association for the Study of Liver Diseases; Practice Parameters Committee of the American College of Gastroenterology. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46(3):922–38.CrossRefGoogle Scholar
  6. 6.
    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.CrossRefGoogle Scholar
  7. 7.
    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):954–63.CrossRefGoogle Scholar
  8. 8.
    Rengasamy S, Ali SM, Sistla SC, Lakshmi CP, Harichandra Kumar KT. Comparison of 2 days versus 5 days of octreotide infusion along with endoscopic therapy in preventing early rebleed from esophageal varices: a randomized clinical study. Eur J Gastroenterol Hepatol. 2015;27(4):386–92.CrossRefGoogle Scholar
  9. 9.
    Banares R, Albillos A, Rincon D, Alonso S, Gonzalez 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):609–15.CrossRefGoogle Scholar
  10. 10.
    Committee ASoP, Hwang JH, Shergill AK, Acosta RD, Chandrasekhara V, Chathadi KV, et al. The role of endoscopy in the management of variceal hemorrhage. Gastrointest Endosc. 2014;80(2):221–7.CrossRefGoogle Scholar
  11. 11.
    de Franchis R, Baveno VF. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol. 2010;53(4):762–8.CrossRefGoogle Scholar
  12. 12.
    Laine L, Cook D. Endoscopic ligation compared with sclerotherapy for treatment of esophageal variceal bleeding. A meta-analysis. Ann Intern Med. 1995;123(4):280–7.CrossRefGoogle Scholar
  13. 13.
    Garcia-Tsao G, Bosch J. Management of varices and variceal hemorrhage in cirrhosis. N Engl J Med. 2010;362(9):823–32.CrossRefGoogle Scholar
  14. 14.
    Boyer TD, Haskal ZJ, American Association for the Study of Liver Diseases. The role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension. Hepatology. 2005;41(2):386–400.CrossRefGoogle Scholar
  15. 15.
    Loffroy R, Estivalet L, Cherblanc V, Favelier S, Pottecher P, Hamza S, et al. Transjugular intrahepatic portosystemic shunt for the management of acute variceal hemorrhage. World J Gastroenterol. 2013;19(37):6131–43.CrossRefGoogle Scholar
  16. 16.
    Augustin S, Muntaner L, Altamirano JT, Gonzalez A, Saperas E, Dot J, et al. Predicting early mortality after acute variceal hemorrhage based on classification and regression tree analysis. Clin Gastroenterol Hepatol. 2009;7(12):1347–54.CrossRefGoogle Scholar
  17. 17.
    Hou MC, Lin HC, Liu TT, Kuo BI, Lee FY, Chang FY, et al. Antibiotic prophylaxis after endoscopic therapy prevents rebleeding in acute variceal hemorrhage: a randomized trial. Hepatology. 2004;39(3):746–53.CrossRefGoogle Scholar
  18. 18.
    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(5):509–18.CrossRefGoogle Scholar
  19. 19.
    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(1):11–21.CrossRefGoogle Scholar
  20. 20.
    Lira A, Pinsky MR. Choices in fluid type and volume during resuscitation: impact on patient outcomes. Ann Intensive Care. 2014;4:38.CrossRefGoogle Scholar
  21. 21.
    Caldwell SH, Hoffman M, Lisman T, Macik BG, Northup PG, Reddy KR, et al. Coagulation disorders and hemostasis in liver disease: pathophysiology and critical assessment of current management. Hepatology. 2006;44(4):1039–46.CrossRefGoogle Scholar
  22. 22.
    Youssef WI, Salazar F, Dasarathy S, Beddow T, Mullen KD. Role of fresh frozen plasma infusion in correction of coagulopathy of chronic liver disease: a dual phase study. Am J Gastroenterol. 2003;98(6):1391–4.CrossRefGoogle Scholar
  23. 23.
    Marti-Carvajal AJ, Sola I. Vitamin K for upper gastrointestinal bleeding in patients with acute or chronic liver diseases. Cochrane Database Syst Rev. 2012;9:CD004792.Google Scholar
  24. 24.
    Ejlersen E, Melsen T, Ingerslev J, Andreasen RB, Vilstrup H. Recombinant activated factor VII (rFVIIa) acutely normalizes prothrombin time in patients with cirrhosis during bleeding from oesophageal varices. Scand J Gastroenterol. 2001;36(10):1081–5.CrossRefGoogle Scholar
  25. 25.
    Marti-Carvajal AJ, Karakitsiou DE, Salanti G. Human recombinant activated factor VII for upper gastrointestinal bleeding in patients with liver diseases. Cochrane Database Syst Rev. 2012;3:CD004887.Google Scholar
  26. 26.
    Bosch J, Thabut D, Bendtsen F, D’Amico G, Albillos A, Gonzalez Abraldes J, et al. Recombinant factor VIIa for upper gastrointestinal bleeding in patients with cirrhosis: a randomized, double-blind trial. Gastroenterology. 2004;127(4):1123–30.CrossRefGoogle Scholar
  27. 27.
    Patanwala AE, Acquisto NM, Erstad BL. Prothrombin complex concentrate for critical bleeding. Ann Pharmacother. 2011;45(7–8):990–9.CrossRefGoogle Scholar
  28. 28.
    Koch DG, Arguedas MR, Fallon MB. Risk of aspiration pneumonia in suspected variceal hemorrhage: the value of prophylactic endotracheal intubation prior to endoscopy. Dig Dis Sci. 2007;52(9):2225–8.CrossRefGoogle Scholar
  29. 29.
    Rudolph SJ, Landsverk BK, Freeman ML. Endotracheal intubation for airway protection during endoscopy for severe upper GI hemorrhage. Gastrointest Endosc. 2003;57(1):58–61.CrossRefGoogle Scholar
  30. 30.
    Shaheen NJ, Stuart E, Schmitz SM, Mitchell KL, Fried MW, Zacks S, et al. Pantoprazole reduces the size of postbanding ulcers after variceal band ligation: a randomized, controlled trial. Hepatology. 2005;41(3):588–94.CrossRefGoogle Scholar
  31. 31.
    Lo EA, Wilby KJ, Ensom MH. Use of proton pump inhibitors in the management of gastroesophageal varices: a systematic review. Ann Pharmacother. 2015;49(2):207–19.CrossRefGoogle Scholar
  32. 32.
    Alaniz C, Mohammad RA, Welage LS. Continuous infusion of pantoprazole with octreotide does not improve management of variceal hemorrhage. Pharmacotherapy. 2009;29(3):248–54.CrossRefGoogle Scholar
  33. 33.
    Lo GH, Perng DS, Chang CY, Tai CM, Wang HM, Lin HC. Controlled trial of ligation plus vasoconstrictor versus proton pump inhibitor in the control of acute esophageal variceal bleeding. J Gastroenterol Hepatol. 2013;28(4):684–9.CrossRefGoogle Scholar
  34. 34.
    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):1957–67.CrossRefGoogle Scholar
  35. 35.
    Chojkier M, Conn HO. Esophageal tamponade in the treatment of bleeding varices. A decadel progress report. Dig Dis Sci. 1980;25(4):267–72.CrossRefGoogle Scholar
  36. 36.
    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.CrossRefGoogle Scholar
  37. 37.
    Saad WE, Simon PO Jr, Rose SC. Balloon-occluded retrograde transvenous obliteration of gastric varices. Cardiovasc Intervent Radiol. 2014;37(2):299–315.CrossRefGoogle Scholar
  38. 38.
    Sabri SS, Abi-Jaoudeh N, Swee W, Saad WE, Turba UC, Caldwell SH, et al. Short-term rebleeding rates for isolated gastric varices managed by transjugular intrahepatic portosystemic shunt versus balloon-occluded retrograde transvenous obliteration. J Vasc Interv Radiol. 2014;25(3):355–61.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Division of Pulmonary and Critical Care MedicineUniversity of Michigan Health SystemAnn ArborUSA

Personalised recommendations