Portal Hypertension and Oesophageal Varices Bleeding

Resuscitation and Initial Management
Vasoactive therapy
Antibiotic Administration
Endoscopic Therapy
Rescue Therapy

Acute variceal bleeding is a dangerous complication of portal hypertension. Mortality rates have decreased from 50% to 15% over the last three decades. In order to ensure that patients with acute variceal bleeding have the best chance of survival it essential that there is a prompt standardised approach to management. This includes airway protection, judicious volume resuscitation, vasoactive therapy, antibiotic prophylaxis and endoscopic intervention.

All patients with known varices will be given a letter instructing that they be transferred directly to Groote Schuur if they are bleeding.

Peripheral hospitals (Somerset, Victoria, Mitchell’s Plein) will encounter patients with variceal bleeding – either new patients or patients known with varices that have presented to their emergency units.

Resuscitation and Initial Management

Patients who are alert and who do not have massive bleeding/haematemesis should be attached to a pulse oximeter and receive supplemental oxygen if necessary. Encephalopathic patients and patients with massive bleeding and haematemesis are at high risk for aspiration. It should be considered at an early stage whether intubation is necessary to secure and protect the airway.  

• It is essential to establish IV access with two large bore intravenous catheters (14-18g). It may be necessary to rapidly administer large volumes of fluids & blood products. 
• Fluids should be warmed before being administered and if necessary high volume infusion sets should be used.  
• Consider inserting a central venous catheter.

Initial fluid administration (normal saline) should be administered to maintain a systolic blood pressure above 100mmHg. Saline administration should be minimised (as it will worsen ascites and oedema) and blood products should be used as soon as available.

• Packed red cells should be administered to achieve haemoglobin between 8-10g/dl. 
• FFP should be administered to get the INR <2.0. 
• Be cautious about fluid overload in patients with cirrhosis.
• Platelets should only be given to bleeding patients with a platelet count below 50. 
• If available a thrombo-elastogram may be useful in correcting coagulopathy.

Vasoactive therapy

Octreotide is indicated for bleeding from oesophageal or gastric varices. In patients who present with upper GIT bleeding it should be started as soon possible after endoscopy confirms a variceal bleed. It may be started before the endoscopy in patients known with varices that present with upper GIT bleeding. Octreotide is not a substitute for endoscopic control of bleeding varices.

The patient should be started on Propranolol when the octreotide is stopped and the patient is haemodynamically stable with a stable Haemoglobin.  The normal starting dose is Propranolol 20mg orally 12 hourly.

Re-bleeding is most common in the first 24 hours. The propranolol should ideally only be started once it is clear that the patient is no longer bleeding & after the period when re-bleeding is most likely to occur. This usually means that the octreotide should be continued for at least 48 hours.

Dose:

•  100ug IV bolus followed by a continuous infusion of 50ug per hour.

Strength:

 Octreotide comes in two strengths:

• 0.1mg vials
• 0.5mg vials
• 1mg = 1000ug
• 0.1mg =100ug (10 amps = 1000ug)
• 0.5mg = 500ug (2amps =1000ug)

Administration:

Octreotide can be mixed in 0.9% saline or 5% dextrose. Dextrose is preferred as these patients are usually sodium restricted. Octreotide is stable for 24 hours after being mixed.

If 1000ug is added to 200mls (5ug/ml) then the infusion should be @ 10 mls per hour to administer 50ug per hour.

Duration of therapy: 3-5 days

Antibiotic Administration

The presence of bacterial sepsis has been shown to be associated with increased mortality and an increased risk of re-bleeding. 66% of cirrhotic patients who present with acute variceal bleeding develop an infection during the hospital admission (spontaneous bacterial peritonitis, pneumonia, UTIs)

The administration of prophylactic antibiotics for 7 days after an acute variceal bleed is associated with improved survival.

The first choice of antibiotics is Ceftriaxone 1g IV 12 hourly and Ampicillin 1gm six hourly. An alternative is Ciprofloxacin 400mg IV 12 hourly.

Endoscopic Therapy

Unstable patients with severe acute GIT bleeding need immediate endoscopy after initial resuscitation. All other patients must be scoped within 12 hours of presentation.

Secondary level hospitals (Somerset, Victoria and Mitchell’s Plein) need to have 24-hour access to endoscopic equipment, the skill and equipment to band varices and to institute balloon tamponade.

The HPB fellow and consultant on call are available to assist at any of these hospitals. Consultants at any of these hospitals who feel they need more experience in banding varices are welcome to come to the varices scope list at Groote Schuur on Tuesdays from 09h30 – 12h00 (please contact the unit to arrange this). The HPB registrars should regularly attend the Tuesday varices list.

All individuals on the GIT scope roster must be capable of banding varices. The HPB consultant on call must be informed of all known varices patients presenting with acute bleeding and will be available to assist if necessary.

• Lactulose 10 ml tds aiming for 2 -3 stools a day to help clear melaena from gut. Lactulose dosage adjusted according to number of stools.
• Vitamin K 10 mg IVI daily
• Nystatin 1ml tds if jaundiced
• Thiamine 100 mg IVI if alcoholic liver disease

 Monitor for hypoglycaemia.

Rescue Therapy

Sengstaken tube                                                                                                                          

Balloon tamponade is used as a temporising measure (maximum 24 hours) in patients with uncontrollable variceal bleeding.

TIPS

TIPS is indicated in patients with variceal bleeds not controlled despite combined pharmacological and endoscopic therapy.