Upper Gastrointestinal Bleed ✅

Oesophageal Variceal Bleeding

🩸 Oesophageal Variceal Bleeding - Comprehensive Management (Makindo)

⚠️ Medical Emergency: Acute variceal haemorrhage carries a 30–50% mortality per bleed. Management is time-critical: treat on suspicion, not confirmation. Terlipressin + antibiotics + restrictive transfusion should be started immediately. Endoscopy stops the bleed - vasoconstriction buys survival.

📖 Background

• Oesophageal varices result from portal hypertension, most commonly due to cirrhosis.
• Portal hypertension causes dilation of submucosal oesophageal veins, which rupture under high pressure.
• Bleeding is often brisk, recurrent, and haemodynamically catastrophic.

🧬 Pathophysiology (Why these treatments work)

• Normal portal pressure: < 6 mmHg
• Varices form: ≥ 10 mmHg
• Bleeding risk rises sharply: ≥ 12 mmHg
• Splanchnic vasodilatation (NO-mediated) ↑ portal inflow.
• Vasoactive drugs ↓ portal venous inflow → ↓ variceal wall tension.

🚑 Initial Resuscitation (ABCD first)

• Airway: Early intubation if massive haematemesis, encephalopathy, or shock.
• Breathing: High-flow oxygen.
• Circulation:
  • 2 × large-bore IV cannulae.
  • Cautious crystalloid boluses.
  • Restrictive transfusion: target Hb 7–8 g/dL.
  • Avoid over-transfusion (↑ portal pressure → rebleeding).
• Disability: Assess encephalopathy.

🧪 Investigations

• FBC, U&E, LFTs, clotting, lactate.
• Group & crossmatch (≥ 6 units if unstable).
• ABG if shocked or encephalopathic.
• Urgent OGD once stabilised (within 12 hours).

💊 Pharmacological Therapy (Start Immediately)

🔹 Vasoactive Therapy

• Terlipressin (first-line in UK)
  • 2 mg IV every 4 hours for first 48 hours
  • Then 1 mg IV every 4 hours
  • Total duration: 3–5 days (stop after haemostasis achieved)
• Mechanism: Splanchnic vasoconstriction → ↓ portal inflow.
• Contraindications / caution: IHD, severe PVD, uncontrolled hypertension, arrhythmias.

🔹 Antibiotic Prophylaxis (MANDATORY)

• Why: Bacterial translocation increases rebleeding and mortality.
• IV Ceftriaxone (preferred in UK):
  • 1 g IV once daily for 7 days
  • Especially Child–Pugh B or C
• Alternatives:
  • Norfloxacin 400 mg PO BD × 7 days
  • Ciprofloxacin 500 mg PO BD × 7 days

🔹 Encephalopathy Prevention

• Lactulose: 20–30 mL PO/NG TDS
• Titrate to 2–3 soft stools/day

🎯 Endoscopic Therapy (Definitive)

• Endoscopic variceal band ligation - treatment of choice.
• Sclerotherapy if banding not feasible.
• Achieves haemostasis in ~90% when combined with drugs.

🚨 Salvage / Rescue Therapy

• Balloon tamponade (Sengstaken–Blakemore or Minnesota tube)
  • Temporary bridge only
  • Maximum 24 hours
  • High risk: aspiration, oesophageal necrosis
• TIPS (Transjugular Intrahepatic Portosystemic Shunt)
  • Indicated for refractory or recurrent bleeding
  • Creates low-resistance channel between portal and hepatic veins
  • Risk: hepatic encephalopathy

🛡️ Secondary Prophylaxis (After Acute Bleed)

• Non-selective β-blockers
  • Propranolol 20–40 mg BD (titrate to HR 55–60)
  • Carvedilol 6.25 mg OD → 12.5 mg OD
• Repeat endoscopic band ligation every 2–4 weeks until eradication.
• Optimise cirrhosis management (alcohol abstinence, nutrition, surveillance).

💡 Exam & On-Call Pearls

• Cirrhotic + haematemesis = variceal bleed until proven otherwise.
• Do not wait for endoscopy to start terlipressin and antibiotics.
• Normal Hb early does not exclude massive bleeding.
• Terlipressin is the only vasoactive drug shown to improve survival.