Management of Acute Variceal Bleeding

Abstract

Acute variceal bleeding could be a fatal complication in patients with liver cirrhosis. In patients with decompensated liver cirrhosis accompanied by ascites or hepatic encephalopathy, acute variceal bleeding is associated with a high mortality rate. Therefore, timely endoscopic hemostasis and prevention of relapse of bleeding are most important. The treatment goals for acute variceal bleeding are to correct hypovolemia; achieve rapid hemostasis; and prevent early rebleeding, complications related to bleeding, and deterioration of liver function. If variceal bleeding is suspected, treatment with vasopressors and antibiotics should be initiated immediately on arrival to the hospital. Furthermore, to obtain hemodynamic stability, the hemoglobin level should be maintained at >8 g/dL, systolic blood pressure >90 to 100 mm Hg, heart rate <100/min, and the central venous pressure from 1 to 5 mm Hg. When the patient becomes hemodynamically stable, hemostasis should be achieved by performing endoscopy as soon as possible. For esophageal variceal bleeding, endoscopic variceal ligation is usually performed, and for gastric variceal bleeding, endoscopic variceal obturation is performed primarily. If it is considered difficult to achieve hemostasis through endoscopy, salvage therapy may be carried out while keeping the patient hemodynamically stable.

Highlights from the 50th Seminar of the Korean Society of Gastrointestinal Endoscopy

“…Endoscopic treatment of active bleeding, and adequate preventive measures, are essential for preventing deterioration of the patient's condition. In this session, severity assessment and obtaining hemodynamic stability, medical therapy including administration of splanchnic constrictors (e.g., terlipressin or octreotide), and administration of prophylactic antibiotics were discussed 4. Since endoscopic variceal ligation is the main therapy for acute variceal bleeding, it should be performed as soon as the patient becomes hemodynamically stable.…”

Endoscopic Variceal Ligation followed by Argon Plasma Coagulation Against Endoscopic Variceal Ligation Alone

“…4,5 Variceal hemorrhage is a lethal complication of portal hypertension and liver cirrhosis, particularly in patients with liver decompensation. 6 The 1-year rate of a first variceal hemorrhage is around 12%. 7 The 6-week mortality is approximately 20%, ranging from 0% among patients with Child class A disease to about 30% among patients with Child class C disease.…”

Neonatal hemochromatosis associated with rupture of esophageal varices

“…The second point is that we used an esophageal balloon catheter to treat ruptured esophageal varices because endoscopic devices were too large to use in this infant (weight, 3,418 g on the first day of hematemesis). Balloon tamponade is used in patients who are too hemodynamically unstable to undergo an endoscopic procedure or in patients in whom endoscopic hemostasis has failed . There have been no previous reports, however, on the use of balloon tamponade for esophageal variceal bleeding in children.…”

“…Balloon tamponade is used in patients who are too hemodynamically unstable to undergo an endoscopic procedure or in patients in whom endoscopic hemostasis has failed. 5 There have been no previous reports, however, on the use of balloon tamponade for esophageal variceal bleeding in children.…”