Gastroenterology Book

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Esophageal VaricesAka: Variceal Bleeding

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  1. See Also
    1. Cirrhosis
    2. Upper GI Bleed
  2. Pathophysiology
    1. See Portal Hypertension
    2. Complication of Cirrhosis (found in 50% of cases)
      1. Typically involve distal 2-5 cm of esophagus
  3. Screening Protocol
    1. Initial: Endoscopy for all patients with Cirrhosis
    2. Repeat screening
      1. No varices: Repeat every 3 years
      2. Small varices: Yearly
  4. Management: Acute variceal bleeding Medical Management
    1. See Upper GI Bleed
    2. Endoscopy as soon as possible if available
      1. See below under invasive management
    3. Octreotide 100 ug IV bolus, then 50 ug/hour
      1. Long-acting somatostatin analog
      2. Preferred vasoactive agent in Upper GI Bleed
    4. Intravenous Vasopressin
      1. Used with Nitroglycerin (Risk of coronary ischemia)
    5. Balloon tamponade
      1. Tamponade varices in refractory cases (80% effective)
        1. Esophageal varices
        2. Gastric fundus varices
      2. Rebleeding occurs in up to 50% of cases
        1. More definitive therapy needed after bleeding stops
      3. High complication rate (15%)
        1. Perforation
        2. Aspiration
        3. Pressure-induced Ulceration
      4. Balloon types
        1. Sengstaken-Blakemore tube
        2. Linton-Nachlas tube
        3. Minnesota tube
  5. Management: Acute variceal bleeding Invasive Management
    1. Endoscopic sclerotherapy or banding
      1. Successful banding
        1. Repeat endoscopy at 3 and 6 months and annually
        2. Banding may be repeated at repeat endoscopy
      2. Unsuccessful banding (continued bleeding)
        1. Balloon Tamponade (see above) and
        2. TIPS and other interventions as below
    2. Transjugular intrahepatic Portosystemic Shunt (TIPS)
      1. Shunt from hepatic vein to intrahepatic portal vein
      2. Commonly effective measure in variceal bleeding
      3. Preventive of future rebleeding events
    3. Emergency Surgical portacaval shunts
      1. Rarely effective and high mortality rate
  6. Management: Prevention of variceal bleeding
    1. See Portal Hypertension
    2. Primary prevention
      1. Indications
        1. Hepatic Vein Pressure Gradient (HPVG) >5 mmHg
        2. Endoscopic criteria
          1. Large esophageal varices
          2. Small esophageal varices
            1. High Child-Pugh Score
            2. Varices with red wale markings
      2. Efficacy
        1. Reduce risk of bleeding from 45% to 22%
      3. Mechanism
        1. Reduce portal pressure gradient
        2. Reduce azygous blood flow and variceal pressure
      4. Agents (target Heart Rate reduction 20 to 25%)
        1. Goal: Reduce HPVG by 20% or <12 mmHg
        2. Propranolol (preferred first line agent)
          1. Start at 10 mg PO tid
          2. Minimum effective dose: 40 mg PO bid
          3. Titrate to 80 mg PO bid if needed
        3. Nadolol 20 mg PO qd
        4. Isosorbide mononitrate (alternative)
          1. Use if Propranolol contraindicated
          2. Dose: 20 mg PO bid
      5. Surgery: Esophageal banding (Variceal band ligation)
        1. As effective as Propranolol in bleeding prevention
        2. Fewer adverse effects than medication management
        3. Lui (2002) Gastroenterology 123:735
    3. Secondary prevention (prior episode of bleeding)
      1. Isosorbide mononitrate 20 mg PO bid
      2. Esophageal banding (Variceal band ligation)
      3. Sclerotherapy to varices (variable efficacy)
      4. Transjugular intrahepatic Portosystemic Shunt (TIPS)
      5. LeVeen Shunt (not recommended due to high mortality)
  7. Prognosis
    1. Predictors of mortality with variceal bleeding
      1. Active bleeding during endoscopy
      2. Encephalopathy
      3. Ascites
      4. Serum Bilirubin increased
      5. Aspartate Aminotransferase increased
      6. Prothrombin Time increased
      7. Graham (1981) Gastroenterology 80:800
    2. Rebleeding Events after initial bleeding episode
      1. Highest risk in first 72 hours
      2. Rebleeding risk is 50% in first 10 days
      3. Risks for re-bleeding
        1. Age over 60 years
        2. Renal Failure
        3. Large esophageal varices
        4. Severe initial bleeding with Hemoglobin < 8 g/dl
    3. Overall Risk of esophageal varice bleeding: 10-30%/year
    4. Risk of bleeding from large varices: 40 to 45% per year
      1. Higher risk with varices with red wale markings
      2. Higher risk with advanced Child-Pugh Score
    5. Risk of death from each bleeding episode
      1. In hospital event: 15%
      2. Out of hospital event: Approaches 50%
  8. References
    1. Hegab (2001) Postgrad Med 109(2):75
    2. Villaneuva (1996) 334:1624
    3. De Franchis (2004) Gastroenterology 126:1860

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