UK guidelines on the management of variceal haemorrhage in cirrhotic patients

Abstract

These updated guidelines on the management of variceal haemorrhage have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the liver section of the BSG. The original guidelines which this document supersedes were written in 2000 and have undergone extensive revision by 13 members of the Guidelines Development Group (GDG). The GDG comprises elected members of the BSG liver section, representation from British Association for the Study of the Liver (BASL) and Liver QuEST, a nursing representative and a patient representative. The quality of evidence and grading of recommendations was appraised using the AGREE II tool.The nature of variceal haemorrhage in cirrhotic patients with its complex range of complications makes rigid guidelines inappropriate. These guidelines deal specifically with the management of varices in patients with cirrhosis under the following subheadings: (1) primary prophylaxis; (2) acute variceal haemorrhage; (3) secondary prophylaxis of variceal haemorrhage; and (4) gastric varices. They are not designed to deal with (1) the management of the underlying liver disease; (2) the management of variceal haemorrhage in children; or (3) variceal haemorrhage from other aetiological conditions.

Should vasoconstrictors be considered in a cirrhotic patient with acute non-variceal upper gastrointestinal bleeding?

“…Thus, a diagnosis of variceal bleeding was initially considered. Proton pump inhibitors are not recommended for the treatment of variceal bleeding in liver cirrhosis [5] . Thus, we did not prescribe proton pump inhibitors to this patient at his admission.…”

“…The first-line choice of pharmacological therapy for the management of variceal bleeding is vasoconstrictors, including terlipressin, somatostatin, and octreotide [1][2] . The use of pump proton inhibitors is compromised for the management of variceal bleeding in liver cirrhosis according to the current UK guidelines [5] . By comparison, a small proportion of acute upper gastrointestinal bleeding episodes in liver cirrhosis are attributed to the peptic ulcer or other non-variceal sources [6][7] , in which case pump proton inhibitors are the standard choice of therapy.…”

“Double band” technique for intractable or recurrent esophageal variceal hemorrhage: An alternative rescue method

“…Early recurrent bleeding (within 5 days) can be observed in nearly 8%-20% of patients with cirrhosis and is associated with a high risk for death, particularly in patients with a high hepatic venous pressure gradient and fibrotic varix caused by previously repeated banding (1). For such patients, when bleeding control fails, a rescue therapy is often required and recommended (2). However, the current rescue methods such as self-expandable esophageal covered metal stent, transjugular intrahepatic portosystemic shunt, and shunt surgery are so expensive and complex that cannot be performed in every unit or they are also associated with additional mortalities such as encephalopathy, esophageal necrosis, or perforation (2).…”

“…For such patients, when bleeding control fails, a rescue therapy is often required and recommended (2). However, the current rescue methods such as self-expandable esophageal covered metal stent, transjugular intrahepatic portosystemic shunt, and shunt surgery are so expensive and complex that cannot be performed in every unit or they are also associated with additional mortalities such as encephalopathy, esophageal necrosis, or perforation (2). Consequently, attempting an alternative endoscopic intervention before suggesting any of the abovementioned complex rescue therapies may be a more appropriate approach.…”

“…All recommended rescue therapies have complex properties and a higher mortality and morbidity rate than endoscopic variceal banding (2,4). Therefore, we used the "double band" technique for our patient based on our previous experience.…”