Clinical question: What is appropriate inpatient management of a cirrhotic patient with acute esophageal or gastric variceal bleeding?
Study design: Guidance document developed by expert panel based on literature review, consensus conferences and authors’ clinical experience.
Background: Practice guidelines for the diagnosis and treatment of gastroesophageal hemorrhage were last published in 2007 and endorsed by several major professional societies. Since then, there have been a number of randomized controlled trials (RCTs) and consensus conferences. The American Association for the Study of Liver Diseases (AASLD) published updated practice guidelines in 2016 that encompass pathophysiology, monitoring, diagnosis, and treatment of gastroesophageal hemorrhage in cirrhotic patients. This summary will focus on inpatient management for active gastroesophageal hemorrhage.
Dr. Jinyu Byron Lu
Synopsis of Inpatient Management for Esophageal Variceal Hemorrhage: The authors suggest that all VH requires ICU admission with the goal of acute control of bleeding, prevention of early recurrence, and reduction in 6-week mortality. Imaging to rule out portal vein thrombosis and HCC should be considered. Hepatic-Venous Pressure Gradient (HVPG) greater than 20 mm Hg is the strongest predictor of early rebleeding and death. However, catheter measurements of portal pressure are not available at most centers. As with any critically ill patient, stabilization of respiratory status and ensuring hemodynamic stability with volume resuscitation is paramount. RCTs evaluating transfusion goals suggest that a restrictive transfusion goal of HgB 7 g/dL is superior to a liberal goal of 9 g/dL. The authors hypothesize this may be related to lower HVPG observed with lower transfusion thresholds. In terms of treating coagulopathy, RCTs evaluating recombinant VIIa have not shown clear benefit. Correction of INR with FFPs similarly not recommended. No recommendations are made regarding utility of platelet transfusions. Vasoactive drugs should be administered when VH is suspected with the goal of decreasing splanchnic blood flow. Octreotide is the only vasoactive drug available in the United States. RCTs show that antibiotics administered prophylactically decrease infections, recurrent hemorrhage, and death. Ceftriaxone 1 g daily is the drug of choice in the United States and should be given up to a maximum of 7 days. A reasonable strategy is discontinuation of prophylaxis concurrently with discontinuation of vasoactive agents. After stabilization of hemodynamics, patients should proceed to endoscopy no more than 12 hours after presentation. Endoscopic Variceal Ligation (EVL) should be done if signs of active or recent variceal bleeding are found. After EVL, select patients at high risk of rebleeding (Child-Pugh B with active bleeding seen on endoscopy or Child-Pugh C patients) may benefit from TIPS within 72 hours. If TIPS is done, vasoactive agents can be discontinued. Otherwise, vasoactive agents should continue for 2-5 days with subsequent transition to nonselective beta blockers (NSBB) such as nadolol or propranolol. For secondary prophylaxis of esophageal bleeding, combination EVL and NSBB is first-line therapy. If recurrent hemorrhage occurs while on secondary prophylaxis, rescue TIPS is recommended.
Synopsis of Inpatient Management for Gastric Variceal Hemorrhage: Management of Gastric Variceal Hemorrhage is similar to Esophageal Variceal (EV) Hemorrhage and encompasses volume resuscitation, vasoactive drugs, and antibiotics with endoscopy shortly thereafter. Balloon tamponade can be used as a bridge to endoscopy in massive bleeds. In addition to the above, anatomic location of Gastric Varices (GV) affects choice of intervention. GOV1 varices extend from the gastric cardia to the lesser curvature and represent 75% of GV. If these are small, they can be managed with EVL. Otherwise these can be managed with injection of cyanoacrylate glue. GOV2 varices extend from the gastric cardia into the fundus. Isolated GV type 1 varices (IGV1) are located entirely in the fundus and have the highest propensity for bleeding. For these latter two types of “cardio-fundal varices” TIPS is the preferred intervention to control acute bleeding. Data on the efficacy of secondary prophylaxis for GV bleeding is limited. A combination of NSBB, cyanoacrylate injection, or TIPS can be considered. Balloon Occluded Retrograde Transvenous Obliteration (BRTO) can be considered if fundal varices are associated with a large gastrorenal or splenorenal collateral. However, no RCTs have compared BRTO with other strategies. Isolated GV type 2 (IGV2) varices are not localized to the esophageal or gastric cardio-fundal region and are rare in cirrhotic patients but tend to occur in pre-hepatic portal hypertension. Management requires multidisciplinary input from endoscopists, hepatologists, interventional radiologists, and surgeons.
Bottom line: For esophageal variceal bleeding related to cirrhosis: volume resuscitation, antibiotic prophylaxis, and vasoactive agents are mainstays of therapy to stabilize patient for endoscopic intervention within 12 hours. This should be followed by early TIPS within 72 hours in high risk patients.
A similar approach applies to gastric variceal bleeding, but interventional management is dependent on the anatomic location of the varices in question.
Citations: Garcia-Tsao G et al. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis and management – 2016 practice guidance by the American Association for the Study of Liver Diseases. Hepatology 2017 Jan;65[1]:310-35.
Dr. Lu is a hospitalist at Cooper University Hospital in Camden, N.J.