What are the AASLD treatment guidelines for variceal bleeding?

Updated: Jul 30, 2018
  • Author: David C Wolf, MD, FACP, FACG, AGAF, FAASLD; Chief Editor: BS Anand, MD  more...
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For patients who present with acute esophageal VH, the AASLD guidelines indicate the following [72] :

  • Conservative transfusion of packed red blood cell (PRBC): Starting to transfuse when the hemoglobin reaches a threshold of around 7 g/dL, with the goal of maintaining it between 7 and 9 g/dL.
  • Short-term (maximum 7 days) antibiotic prophylaxis should be instituted in any patient with cirrhosis and gastrointestinal hemorrhage.
  • Intravenous (IV) ceftriaxone 1 g/24 h is the antibiotic of choice and should be used for a maximum of 7 days (consider discontinuing when hemorrhage has resolved and vasoactive drugs discontinued).
  • Vasoactive drugs (somatostatin or its analogue, octreotide; vasopressin or its analogue, terlipressin) should be initiated as soon as VH is suspected.
  • EGD should be performed within 12 hours of admission and once the patient is hemodynamically stable.
  • If a variceal source is confirmed/suspected, EVL should be performed.
  • In patients at high risk of failure or rebleeding (Child-Turcotte-Pugh [CTP] class C cirrhosis or CTP class B with active bleeding on endoscopy) who have no contraindications for TIPS, an “early” (preemptive) TIPS within 72 hours from EGD/EVL may benefit selected patients.
  • For patients in whom an early TIPS is not performed, IV vasoactive drugs should be continued for 2-5 days and nonselective beta-blockers initiated once vasoactive drugs are discontinued. Rescue TIPS is indicated in these patients if hemorrhage cannot be controlled or if bleeding recurs despite the use of vasoactive drugs plus EVL.
  • In patients in whom TIPS is performed successfully, IV vasoactive drugs can be discontinued.

For individuals who have recovered from an episode of acute esophageal VH, the AASLD recommends the following [72] :

  • First-line therapy in the prevention of rebleeding: The combination of nonselective beta-blockers plus EVL
  • Patients who have had successful placement of a TIPS during the acute episode do not require nonselective beta-blockers or EVL.
  • TIPS is the recommended rescue therapy in patients who experience recurrent hemorrhage despite the use of combination therapy nonselective beta-blockers plus EVL.

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