Gastroenterology Hepatology
Liver transplantation: pretransplant management - variceal bleeding
-
How can I be sure that the patient has variceal bleeding?
-
A tabular or chart listing of features and signs and symptoms
-
How can I confirm the diagnosis?
- What other diseases, conditions, or complications should I look for in patients with variceal bleeding?
-
What is the right therapy for the patient with variceal bleeding?
-
What is the most effective initial therapy?
-
Listing of usual initial therapeutic options, including guidelines for use, along with expected result of therapy.
-
A listing of a subset of second-line therapies, including guidelines for choosing and using these salvage therapies
-
Listing of these, including any guidelines for monitoring side effects.
-
How should I monitor the patient with variceal bleeding?
-
What's the evidence?
How can I be sure that the patient has variceal bleeding?
Upper gastrointestinal hemorrhage due to bleeding from esophageal varices, gastric varices, and portal hypertensive gastropathy occurs in patients with portal hypertension from cirrhosis. Bleeding from gastroesophageal varices usually presents with hematemesis, melena, or both. Occult bleeding, particularly due to portal hypertensive gastropathy, may present as unexplained anemia. Bleeding from ectopic sites of variceal formation, other than the esophagus or stomach, is uncommon.
A tabular or chart listing of features and signs and symptoms
Hematemesis
Melena
Unexplained anemia
SIRS (See chapter "Liver transplantation: pretransplant management – systemic inflammatory response syndrome.")
How can I confirm the diagnosis?
Esophagogastroduodenoscopy is the most appropriate investigation to determine that a cirrhotic patient is experiencing or has had a recent gastroesophageal variceal hemorrhage. According to AASLD (American Association for the Study of Liver Disease) guidelines, all persons with suspected gastroesophageal variceal bleeding should undergo upper endoscopic inspection within 12 hours of hospital admission.
What other diseases, conditions, or complications should I look for in patients with variceal bleeding?
What other diseases, conditions, or complications should I look for in patients with possible gastroesophageal bleeding?
Bleeding erosive esophagitis
Peptic ulcer disease
Stress gastritis
GAVE (gastric antral vascular ectasia)
Dieulefoy's lesion
Aortoenteric fistula
Gastric or esophageal cancer
Swallowed blood from nasal bleeding
Osler-Weber-Rendu syndrome (i.e., hereditary hemorrhagic telangiectasia)
Peutz Jeghers Syndrome
What is the right therapy for the patient with variceal bleeding?
Therapy for variceal bleeding includes the following:
Admit to an intensive care unit
Resuscitate with blood products as appropriate.
Initiate pharmacologic therapy: octreotide IV; proton pump inhibitors IV; broad spectrum antibiotics IV.
Transfer to a center with appropriate endoscopy services, if such are not available at the first site, when patient is stable.
On transfer, admit to ICU, and request urgent consultation with provider of endoscopy.
When varices are confirmed by endoscopy, endoscopic ligation or injection of scleroscant is the appropriate therapy.
Failure to control hemorrhage endoscopically should lead to placement of an endotracheal breathing tube, assisted ventilation, and placement of a Blakemore-Sengstaken tamponade tube.
Failure to control hemorrhage, or massive recurrent hemorrhage, is an indication for TIPS (transjugular intrahepatic portocaval shunting.
What is the most effective initial therapy?
The most effective initial therapy involves the following:
Prior to endoscopy, start octreotide IV; proton pump inhibitors IV; broad spectrum antibiotics IV.
Endoscopic treatments are rubber band ligation and injection of sclerosants (sodium morrhuate, ethanolamine).
Temporary tamponade by a Blakemore-Sengstaken tube.
Transjugular intrahepatic portosystemic shunt (TIPS).
Listing of usual initial therapeutic options, including guidelines for use, along with expected result of therapy.
Based on the AASLD guidelines (2007):
Patients with suspected variceal hemorrhage need to be admitted to a hospital, with 24-hour access to endoscopic services, including treatment of varices.
Resuscitation prior to transfer is appropriate, particularly in patients who are hemodynamically unstable.
Resuscitation should include IV provision of blood products, and early intubation and assisted ventilation to maintain respiratory status and protect the airway from aspiration.
Prior to endoscopy, when there is reasonable suspicion for variceal hemorrhage, start IV octreotide, IV antibiotics, and IV proton pump inhibitors.
Patients with suspected variceal hemorrhage should have an EGD within 12 hours of hospital admission, and variceal treatment (ligation, injection of sclerosant) undertaken as appropriate.
A listing of a subset of second-line therapies, including guidelines for choosing and using these salvage therapies
Second-line therapies include:
Tamponade by Blakemore-Sengstaken tube
TIPS
Listing of these, including any guidelines for monitoring side effects.
N/A
How should I monitor the patient with variceal bleeding?
Monitoring for variceal bleeding involves:
Frequent, repeated vital signs (BP, pulse, O2 saturation, temperature, mental status)
Serial hemoglobins
Observation for hematemesis and melena
These observations should be undertaken in an intensive care unit for the first 24 hours.
What's the evidence?
Johnson, EA. "Optimizing the care of patients with cirrhosis and gastrointestinal hemorrhage: a quality control study". Aliment Pharmacol Ther. vol. 34. 2011. pp. 76-82.
Wang, YB, Zhang, JY, Gong, JP. " 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. 2015 Dec 5.
"Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis: AASLD guidelines 2007". http:/www.aasld.org/practiceguidlines.
**The original author for this chapter was Michael R. Lucey . The chapter was revised by Dr. Bruce R. Bacon.
Copyright © 2017, 2013 Decision Support in Medicine, LLC. All rights reserved.
No sponsor or advertiser has participated in, approved or paid for the content provided by Decision Support in Medicine LLC. The Licensed Content is the property of and copyrighted by DSM.
Sign Up for Free e-newsletters
ONA Articles
- Takeda to Collaborate With MSKCC on CAR-T Therapies for Multiple Myeloma
- FDA: Number of U.S. Women With Breast Implant-Caused Cancer Has Increased
- Sequential Immunotherapy, Targeted Therapy Linked to Cutaneous Adverse Events in Advanced Melanoma
- NIH Establishes Educational Program on Genomics, Genetics for Oncology Nurses
- Immunotherapy for HER2-positive Breast Cancer: Recent Advances and Combination Therapeutic Approaches
- Oncology Nurse Navigation Facilitates Timely Treatment of Pancreatic Cancer
- Helping Patients Face the Challenge of Eating Healthy During Cancer Treatment
- Oncology Nurses Weigh In on Their Patient-Centered Communication Practices, Needs
- Substitute for Lidocaine
- CART cell therapy for prostate cancer: status and promise
- Immunotherapy for HER2-positive Breast Cancer: Recent Advances and Combination Therapeutic Approaches
- Survey Demonstrates Relationship Between Symptom Burden, Medical Disability Leave Among Myeloproliferative Neoplasms
- A Review of Clinical Outcomes in Patients With Early-Stage Burkitt Lymphoma
- FDA: Number of U.S. Women With Breast Implant-Caused Cancer Has Increased
- USPSTF Still Recommends Against Pancreatic Cancer Screening
Regimen and Drug Listings
GET FULL LISTINGS OF TREATMENT Regimens and Drug INFORMATION
Bone Cancer | Regimens | Drugs |
Brain Cancer | Regimens | Drugs |
Breast Cancer | Regimens | Drugs |
Endocrine Cancer | Regimens | Drugs |
Gastrointestinal Cancer | Regimens | Drugs |
Genitourinary Cancer | Regimens | Drugs |
Gynecologic Cancer | Regimens | Drugs |
Head and Neck Cancer | Regimens | Drugs |
Hematologic Cancer | Regimens | Drugs |
Lung Cancer | Regimens | Drugs |
Other Cancers | Regimens | |
Rare Cancers | Regimens | |
Skin Cancer | Regimens | Drugs |