The management of acute variceal bleeding

Abstract

Summary Variceal haemorrhage is a common medical emergency with a high mortality (30–50%). Adequate resuscitation is vital, and once stabilised the patient should be moved to a high‐dependency area. Antibiotics reduce mortality, and the vasoactive drug terlipressin should be administered if early endoscopy is unavailable. Early endoscopy is essential both to make the diagnosis and to allow therapeutic measures to be performed. The evidence suggests that variceal band ligation is the most effective therapy for oesophageal varices. If gastric varices are found at the index endoscopy the evidence at present is inadequate to be certain which is the best treatment, but both endoscopic therapy with cyanoacrylate or thrombin and transjugular intrahepatic portosystemic stent shunt (TIPSS) have been reported to be of benefit. When initial treatments fail, rescue therapy should be initiated. Most authorities agree that TIPSS is the rescue therapy of choice. Many questions remain concerning the treatment of acute variceal bleeding, particularly the ideal therapy for gastric varices and the role of combination vasoactive and endoscopic therapy. Randomised controlled trials are required to answer these important issues.

Efficacy, Complications and Clinical Outcomes of Endoscopic Sclerotherapy with N-Butyl-2-Cyanoacrylate for Bleeding Gastric Varices

“…Furthermore, it is important to emphasize that there are currently very few other options to treat patients with gastric variceal bleeding [23,24] . The use of TIPSS is limited if there is portal vein thrombosis, a small portal vein or awkward anatomy [25,26] . The use of endoloops to obliterate gastric varices appears promising, but there are only few data documenting its efficacy [27] .…”

Acute Management of Refractory Variceal Bleeding in Liver Cirrhosis by Self-Expanding Metal Stents

“…Over the past decades, a number of treatment options have been implied for the management of VB, including pharmacologic vasoconstriction, physical compression of varices via balloon tamponade and various endoscopic interventions [2]. To date, endoscopic banding ligature is regarded as the standard therapy for acute VB and has widely replaced the formerly used endosopic sclerotherapy [3].…”

Earlier recurrence of esophageal varices, following therapy, in patients with primary biliary cirrhosis (PBC) compared with non-PBC patients

“…Therefore, we should select and combine various therapies according to the circumstances, in reference to previous reports. 24 In conclusion, because of the finding that liver dysfunction caused by PBC is an independent risk factor for earlier recurrence of esophageal varices, we should be extra careful in the follow-up of patients with PBC after therapy for esophageal varices, and should consider combined therapy. Prospective controlled studies should be performed to assess therapy for esophageal varices according to not only the grade of varices and liver function but also the etiology of the liver disease.…”