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Approach to Suspected Variceal Bleeding

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Abstract

Gastroesophageal variceal hemorrhage is a common complication of portal hypertension and a leading cause of death in patients with cirrhosis. The initial approach in a patient with suspected acute variceal bleeding consists of resuscitative measures with a restrictive transfusion strategy, prophylactic antibiotic therapy, and a vasoconstrictive agent, such as terlipressin or octreotide. Endoscopy is an integral part of the evaluation algorithm for suspected variceal hemorrhage. Combination vasopressive drug therapy and endotherapy in the form of endoscopic band ligation is the recommended treatment for acute esophageal variceal bleeding. Injection of tissue adhesives, namely, cyanoacrylate, is the preferred treatment modality for bleeding gastric varices. Transjugular intrahepatic portosystemic shunts or surgically created shunts are excellent salvage procedures. Survivors of variceal hemorrhage should be evaluated for liver transplantation.

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References

  1. Pagliaro L, D’Amico G, Pasta L, Politi F, et al. Portal hypertension in cirrhosis: natural history. In: Bosch J, Groszmann RJ, editors. Portal hypertension. Pathophysiology and treatment. Oxford: Blackwell Scientific; 1994. p. 72–92.

    Google Scholar 

  2. The North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices. Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. A prospective multicenter study. N Engl J Med. 1988;319:983–9.

    Article  Google Scholar 

  3. Moitinho E, Escorsell À, Bandi J–C, et al. Prognostic value of early measurements of portal pressure in acute variceal bleeding. Gastroenterology. 1999;117:626–31.

    Google Scholar 

  4. Menon KV, Shah VH, Kamath PS. The Budd-Chiari syndrome. N Engl J Med. 2004;350:578–85.

    Article  CAS  PubMed  Google Scholar 

  5. Dagradi A. The natural history of esophageal varices in patients with alcoholic liver disease. Am J Gastroenterol. 1972;57:520–40.

    CAS  PubMed  Google Scholar 

  6. Oberhammer E, Paquet KJ, Distelmayer W. Endoscopische Befunde bei portaler Hypertension unter Einschlusz der Nottfallenendoskopie. Therapiewoche. 1978;28:7178–87.

    Google Scholar 

  7. Japanese Research Society For Portal Hypertension. The general rules for recording endoscopic findings on oesophageal varices. Jpn J Surg. 1980;10:84–7.

    Article  Google Scholar 

  8. Sarin SK, Kumar A, Angus PA, Baijal SS, For Asian Pacific Association for the Study of the Liver (APASL) Working Party on Portal Hypertension, et al. Diagnosis and management of acute variceal bleeding: Asian Pacific Association for study of the liver recommendations. Hepatol Int. 2011;5:607–24.

    Article  PubMed Central  PubMed  Google Scholar 

  9. de Franchis R. Evolving consensus in portal hypertension report of the Baveno IV consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol. 2005;43:167–76.

    Article  PubMed  Google Scholar 

  10. Bosch J, Mastai R, Kravetz D, et al. Hemodynamic evaluation of the patient with portal hypertension. Semin Liver Dis. 1986;6:309–17.

    Google Scholar 

  11. Bosch J, Garcia-Pagan JC. Complications of cirrhosis. I. Portal hypertension. J Hepatol. 2000;32:141–56.

    Article  CAS  PubMed  Google Scholar 

  12. Escorsell A, Bandi JC, Moitinho E, et al. Time profile of the haemodynamic effects of terlipressin in portal hypertension. J Hepatol. 1997;26:621–7.

    Article  CAS  PubMed  Google Scholar 

  13. Loannou GN, Doust J, Rockey DC. Systematic review: terlipressin in acute oesophageal variceal haemorrhage. Aliment Pharmacol Ther. 2003;17:53–64.

    Google Scholar 

  14. Escorsell A, Ruiz del Arbol L, Planas R, et al. Multicenter randomized controlled trial of terlipressin versus sclerotherapy in the treatment of acute variceal bleeding: the TEST study. Hepatology. 2000;32:471–6.

    Google Scholar 

  15. Walker S, Stiehl A, Raedsch R, Kommerell B. Terlipressin in bleeding esophageal varices: a placebo-controlled, double-blind study. Hepatology. 1986;6:112–5.

    Article  CAS  PubMed  Google Scholar 

  16. Morelli A, Ertmer C, Lange M, Westphal M. Continuous terlipressin infusion in patients with septic shock: less may be best, and the earlier the better? Intensive Care Med. 2007;33:1669–70.

    Article  PubMed  Google Scholar 

  17. Umgelter A, Reindl W, Schmid RM, Huber W. Continuous terlipressin infusion in patients with persistent septic shock and cirrhosis of the liver. Intensive Care Med. 2008;34:390–1.

    Article  PubMed  Google Scholar 

  18. Burroughs AK, McCormick PA, Hughes MD, et al. Randomized, double-blind, placebo-controlled trial of somatostatin for variceal bleeding. Emergency control and prevention of early variceal rebleeding. Gastroenterology. 1990;99:1388–95.

    Google Scholar 

  19. Gøtzsche PC, Gjørup I, Bonnén H, et al. Somatostatin v placebo in bleeding oesophageal varices: randomised trial and meta-analysis. BMJ. 1995;310:1495–8.

    Google Scholar 

  20. 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 

  21. Cirera I, Feu F, Luca A, et al. Effects of bolus injections and continuous infusions of somatostatin and placebo in patients with cirrhosis: a double-blind hemodynamic investigation. Hepatology. 1995;22:106–11.

    CAS  PubMed  Google Scholar 

  22. Jenkins SA, Nott DM, Baxter JN. Pharmacokinetics of octreotide in patients with cirrhosis and portal hypertension; relationship between the plasma levels of the analogue and the magnitude and duration of the reduction in corrected wedged hepatic venous pressure. HPB Surg. 1998;11:13–21.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  23. Møller S, Brinch K, Henriksen JH, Becker U. Effect of octreotide on systemic, central, and splanchnic haemodynamics in cirrhosis. J Hepatol. 1997;26:1026–33.

    Article  PubMed  Google Scholar 

  24. Escorsell A, Bandi JC, Andreu V, et al. Desensitization to the effects of intravenous octreotide in cirrhotic patients with portal hypertension. Gastroenterology. 2001;120:161–9.

    Google Scholar 

  25. Soares-Weiser K, Brezis M, Tur-Kaspa R, Leibovici L. Antibiotic prophylaxis for cirrhotic patients with gastrointestinal bleeding. Cochrane Database Syst Rev. 2002:CD002907.

    Google Scholar 

  26. Blaise M, Pateron D, Trinchet JC, et al. Systemic antibiotic therapy prevents bacterial infection in cirrhotic patients with gastrointestinal hemorrhage. Hepatology. 1994;20:34–8.

    Google Scholar 

  27. Fernández J, Ruiz del Arbol L, Gómez C, et al. Norfloxacin vs ceftriaxone in the prophylaxis of infections in patients with advanced cirrhosis and hemorrhage. Gastroenterology. 2006;131:1049–56.

    Google Scholar 

  28. de Franchis R. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol. 2010;53:762–8.

    Article  PubMed  Google Scholar 

  29. Sarin N, Monga N, Adams PC. Time to endoscopy and outcomes in upper gastrointestinal bleeding. Can J Gastroenterol. 2009;23:489–93.

    PubMed Central  CAS  PubMed  Google Scholar 

  30. The Copenhagen Esophageal Varices Sclerotherapy Project. Sclerotherapy after first variceal hemorrhage in cirrhosis: a randomized multicenter trial. N Engl J Med. 1984;311:1594–600.

    Article  Google Scholar 

  31. Sarin SK, Govil A, Jain AK, et al. Prospective randomized trial of endoscopic sclerotherapy versus variceal band ligation for esophageal varices: influence on gastropathy, gastric varices and variceal recurrence. J Hepatol. 1997;26:826–32.

    Google Scholar 

  32. Laine L, Cook D. Endoscopic ligation compared with sclerotherapy for treatment of esophageal variceal bleeding. A meta-analysis. Ann Intern Med. 1995;123:280–7.

    Article  CAS  PubMed  Google Scholar 

  33. Sarin SK, Primignani M, Agarwal SR. Gastric varices. In: de Franchis R, editor. Portal hypertension. Proceedings of the third Baveno international consensus workshop on definitions, methodology and therapeutic strategies. London: Blackwell Science; 2001. p. 76–96.

    Google Scholar 

  34. Pitcher JL. Safety and effectiveness of the modified Sengstaken-Blakemore tube: a prospective study. Gastroenterology. 1971;61:291–8.

    CAS  PubMed  Google Scholar 

  35. Wright G, Lewis H, Hogan B, et al. A self-expanding metal stent for complicated variceal hemorrhage: experience at a single center. Gastrointest Endosc. 2010;71:71–8.

    Google Scholar 

  36. Hubmann R, Bodlaj G, Czompo M, et al. The use of self-expanding metal stents to treat acute esophageal variceal bleeding. Endoscopy. 2006;38:896–901.

    Article  CAS  PubMed  Google Scholar 

  37. Saad WEA, Sabri SS. Balloon-occluded Retrograde Transvenous Obliteration (BRTO): technical results and outcomes. Semin Intervent Radiol. 2011;28:333–8.

    Article  PubMed Central  PubMed  Google Scholar 

  38. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey WD, Practice Guidelines. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Am J Gastroenterol. 2007;102:2086–102.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Hepatology, Institute of Liver and Biliary Sciences (ILBS), New Delhi, India

    Kapil Sharma M.D., D.M. & Shiv K. Sarin M.D., D.M., D.Sc., F.N.A.

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  1. Kapil Sharma M.D., D.M.
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  2. Shiv K. Sarin M.D., D.M., D.Sc., F.N.A.
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Corresponding author

Correspondence to Shiv K. Sarin M.D., D.M., D.Sc., F.N.A. .

Editor information

Editors and Affiliations

  1. Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA

    Louis M. Wong Kee Song

  2. Medical College of Wisconsin-Green Bay Campus, Prevea Center for Digestive Health, Green Bay, Wisconsin, USA

    Emmanuel C. Gorospe

  3. Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA

    Todd H. Baron

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Sharma, K., Sarin, S.K. (2016). Approach to Suspected Variceal Bleeding. In: Wong Kee Song, L., Gorospe, E., Baron, T. (eds) GI Endoscopic Emergencies. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-3085-2_4

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  • DOI: https://doi.org/10.1007/978-1-4939-3085-2_4

  • Publisher Name: Springer, New York, NY

  • Print ISBN: 978-1-4939-3084-5

  • Online ISBN: 978-1-4939-3085-2

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