Variceal Bleeding - Diagnosis and Management Summary

Variceal Bleeding - Diagnosis and Management Summary

 • Pathophysiology: usually occurs when hepatic venous pressure gradient (HVPG) >10-12 mmHg in the distal 2-5 cm of the esophagus

 • Screening: baseline EGD at diagnosis unless liver stiffness <20kPa (by FibroScan) and platelets >150 (very low probability)

     o Repeat EGD q2yrs (if ongoing injury/condition), q3yrs (if injury quiescent), or if decomp. event & previously no/small EVs

 • Primary PPX if high risk of bleeding: (1) medium/large size; (2) small w/ red wale signs; (3) decomp. cirrhosis w/ small varices:

     o If medium/large (>5mm): non-selective βB (dosing below), carvedilol (6.25mg QD for 3 days → increase to 6.25mg BID), or serial EVL (endoscopic variceal ligation, q2-8wks until eradication)

     o If small (<5mm): non-sel βB

 • Secondary PPX if prior bleed: combination of non-sel βB + EVL

     o Non-sel βB: nadolol 20-40mg QD or propranolol 20-40mg BID; adjust dose to goal HR 55-60, SBP>90, max dose: propranolol 160mg/320mg QD or nadolol 80mg/160mg QD in patients with/without ascites

     o Serial EVL: repeat q1-4 wk until obliteration, repeat EGD 3-6 mo after obliteration & then q6-12 mo

 • Acute bleeding: IV access, IVF, pRBC (+/-FFP), PPI, octreotide, CTX, EGD (GI). May need intubation, Blakemore as a bridge (GI), TIPS (IR), surgery, Amicar (if ↓fibrinogen). Conservative transfusion: goal Hgb 7-9. See Upper GI Bleeding.

 • Indications for TIPS: early “preemptive” TIPS (<72hrs) in pts with high risk of treatment failure or rebleeding (NEJM 2010;362:2370; “rescue” TIPS if uncontrolled bleeding or if recurs despite max medical & endoscopic therapy

 • Stop βB if: SBP, refractory ascites, HRS, low BP, sepsis; “window hypothesis” 

#Varices #Variceal #Bleeding #Diagnosis #Management #Summary
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