COMMENTARY

The Clinical Management of Gastroesophageal Varices

Rowen K. Zetterman, MD

Disclosures

January 20, 2012

In This Article

Therapy of Acute Variceal Hemorrhage

Patients who develop variceal hemorrhage should be transfused to maintain systemic blood pressure at 100 mm Hg and hemoglobin at ≥ 8 gm/dL.[30] Patients with coronary artery disease may need transfusion to higher hemoglobin levels. It is important to not overtransfuse. The patient's airway should be controlled as necessary and antibiotics administered. Antibiotics can reduce the risk for systemic infection, renal failure, rebleeding, and death.[31,32]Octreotide, a somatostatin analogue, is administered as soon as suspected variceal hemorrhage is identified. This off-label use of octreotide has an uncertain mechanism of action but appears effective in reducing or stopping variceal bleeding. Once initiated, octreotide should be maintained for 2 to 5 days.[10]Vasopressin, a posterior pituitary hormone, is a potent vasoconstrictor that will also reduce portal pressure. It also increases systemic vasoconstriction and has been associated with myocardial infarction and small bowel necrosis.[33] Terlipressin, a long-acting analogue of vasopressin, can reduce mortality from variceal hemorrhage but is not available in the United States.[34]

Balloon tamponade with a Linton-Nachlas or Sengstaken-Blakemore tube can be a bridge to endoscopic therapy in massive variceal hemorrhage. Care should be taken to prevent insufflation of the gastric balloon within the esophagus and an immediate radiograph centered on the xiphoid should be obtained to ensure that placement is correct. Balloon tamponade is 90% effective in stopping bleeding, although about one half of patients will relapse with bleeding when the balloon is released in 24 to 72 hours.

Urgent endoscopy should typically be completed within 12 hours of bleeding. Band ligation is preferred for control of bleeding and is considered the treatment of choice.[10] Side effects include initial dysphagia, esophageal ulceration, and esophageal perforation (rare). Risk for banding-induced ulceration can be reduced by addition of a proton-pump inhibitor. Banding should be repeated until obliteration of varices is complete. Addition of a beta-blocker is useful in secondary prophylaxis. Sclerotherapy of esophageal varices is inferior to band ligation.[35]

Uncontrolled bleeding, defined as continued bleeding at 24 hours, is uncommon when band ligation and octreotide are used.[10] If bleeding continues, repeat banding or placement of TIPS, or surgical shunting should be considered. TIPS placement involves creating an intrahepatic shunt between the portal vein and hepatic vein using a covered stent. This is effectively a side-to-side portosystemic shunt, and, although rebleeding rates are low, hepatic encephalopathy is frequent.[36] Progressive occlusion of the shunt can develop, and hepatic ultrasound should be repeated every 4-6 months to ensure patency.

Gastric varices may be associated with severe bleeding. Gastric banding is associated with significant rebleeding due to gastric ulceration when the band sloughs. The use of detachable snares may be more effective, and is under study. Often, bleeding patients with uncontrolled gastric varices are treated with a surgical shunt or TIPS. Intravariceal injection of polymer (N-butyl-2-cyanoacrylate) can occlude gastric varices[10]but is not available in the United States. Off-label use of 2-octyl cyanoacrylate, which is available in the United States, appears to be more effective than band ligation for gastric varices. Complete obliteration of gastric varices requires repetitive injections and can be supplemented with endoscopic ultrasound to ensure adequate treatment.

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