Makindo Medical Notes

Related Subjects: |Achalasia |Oesophageal Carcinoma |Diffuse Oesophageal spasm |Diffuse Oesophageal Perforation - Rupture |Gastro-Oesophageal Reflux |Barrett's oesophagus |Upper Gastrointestinal Bleed |Oesophageal Variceal Bleeding |Dieulafoy Lesion |Peptic Ulcer Disease |Oesophagogastroduodenoscopy (OGD/EGD) |Hereditary Haemorrhagic Telangiectasia

It’s crucial for healthcare providers to be immunized against Hepatitis B, a potential cause of cirrhosis. Endoscopic screening is recommended for varices in patients with liver cirrhosis to mitigate risks of severe bleeding complications.

About

• Oesophageal variceal bleeding is a common complication of portal hypertension, primarily due to liver cirrhosis.
• Only one-third of all varices actually bleed, but when they do, the bleeding can be massive, with a mortality rate of approximately 50%.
• Always consider other causes of gastrointestinal bleeding in those with liver disease, including gastritis, peptic ulcers, and Mallory-Weiss tears.

Aetiology

• Endothelin-1 (ET-1) and nitric oxide (NO) contribute to increased portal hypertension.
• The portal system carries about 1500 mL of blood from the intestines to the liver each minute. Normal portal pressure is < 6 mmHg, varices form at 10 mmHg, and risk of bleeding increases significantly at pressures ≥ 12 mmHg.

Risk Factors for First Variceal Bleeding

• Variceal size, with larger varices posing a higher risk.
• Advanced Child-Pugh class indicating poorer liver function.
• Presence of “red signs” on varices, such as red streaks or red spots, visible on endoscopy.

Clinical Presentation

• Signs of significant blood loss, including pallor, haematemesis, and melena.
• Signs of hypovolemic shock: hypotension, tachycardia, and postural hypotension.
• Potential signs of hepatic encephalopathy, such as confusion and drowsiness.
• Splenomegaly may be present in cases of established portal hypertension.
• Check for blood or melena on rectal examination to assess gastrointestinal blood loss.

Investigations

• Group and Crossmatch: Prepare at least 6 units of blood for potential transfusion.
• Laboratory Tests: Full blood count (FBC), U&E, LFTs, coagulation profile, and hepatitis serology to assess liver function and screen for hepatitis infection.

Initial Management

• Prioritize ABCs (Airway, Breathing, Circulation) and initiate resuscitation measures with large-bore IV access.
• Consider transfusion for significant blood loss, but avoid excessive fluid resuscitation, as it may worsen portal pressure.
• Correct any coagulopathy with appropriate blood products if needed and consider ICU admission for intensive monitoring.
• Administer ciprofloxacin 500 mg bid for one week to reduce infection risk, which is common in cirrhotic patients with bleeding varices.
• Consider lactulose to reduce ammonia production and minimize the risk of hepatic encephalopathy.

Specific Therapies

• Endoscopic Therapy: Endoscopic band ligation or sclerotherapy to control and stop bleeding in approximately 80% of cases. Look for high-risk markings on endoscopy such as red spots and variceal streaks.
• Vasoactive Medications: IV Terlipressin 2 mg every 6 hours to reduce portal blood flow through vasoconstriction of splanchnic arteries. Avoid in patients with ischemic heart disease. Octreotide can be used as an alternative (50 mcg IV bolus followed by 50 mcg/hour infusion).
• Balloon Tamponade: Using a Sengstaken-Blakemore tube for severe bleeding unresponsive to other treatments. This is a temporary measure due to the risk of complications such as aspiration and oesophageal trauma.
• Transjugular Intrahepatic Portosystemic Shunt (TIPS): Considered in patients with ongoing bleeding despite medical and endoscopic therapy. TIPS involves creating a channel between the portal and hepatic veins to reduce portal pressure.

Prophylaxis and Long-Term Management

• Variceal Band Ligation: Repeated banding sessions to eradicate varices and reduce recurrence risk.
• Non-Selective Beta-Blockers: Oral Propranolol reduces portal pressure but may have compliance issues due to side effects.
• TIPS: Consider for patients with refractory bleeding and those who may be liver transplant candidates.
• Lifestyle and Dietary Modifications: Avoid alcohol, maintain a healthy diet, and monitor liver function regularly.