Variceal Haemorrhage

Patients with liver cirrhosis are at risk of developing portal hypertension (increased portal venous system pressure). One of the most significant complications of portal hypertension is oesophageal varices. These are at risk of rupturing leading to a potentially severe and life-threatening upper gastrointestinal bleed.

Acute treatment of variceal haemorrhage

• ABC
  • patients should be resuscitated prior to endoscopy
  • blood transfusion may be needed
• correct clotting: FFP, vitamin K, platelet transfusions may be required
• vasoactive agents:
  • terlipressin is currently the only licensed vasoactive agent and is supported by NICE guidelines. It has been shown to be of benefit in initial haemostasis and preventing rebleeding
  • octreotide may also be used although there is some evidence that terlipressin has a greater effect on reducing mortality
• prophylactic IV antibiotics
  • have been shown to reduce mortality in patients with liver cirrhosis
  • quinolones are typically used
  • NICE support this in their 2016 guidelines: 'Offer prophylactic intravenous antibiotics for people with cirrhosis who have upper gastrointestinal bleeding.'
• both terlipressin and antibiotics should be given before endoscopy in patients with suspected variceal haemorrhage
• endoscopy: endoscopic variceal band ligation is superior to endoscopic sclerotherapy. NICE recommend band ligation
• Sengstaken-Blakemore tube if uncontrolled haemorrhage
• Transjugular Intrahepatic Portosystemic Shunt (TIPSS) if above measures fail
  • connects the hepatic vein to the portal vein
  • exacerbation of hepatic encephalopathy is a common complication

Prophylaxis of variceal haemorrhage

• non-selective beta-blockers
  • carvedilol is the agent of choice in patients with compensated cirrhosis (more effective at lowering hepatic venous pressure gradient (HVPG) than propranolol)
  • propranolol is generally used in patients with decompensated cirrhosis (Carvedilol has additional α1-blocking (vasodilatory) activity, which can lower systemic blood pressure more profoundly. In decompensated cirrhosis, patients are already prone to systemic hypotension, renal impairment etc)
  • reduced rebleeding and mortality compared to placebo
• endoscopic variceal band ligation (EVL)
  • superior to endoscopic sclerotherapy
  • this is supported by NICE who recommends: 'Offer endoscopic variceal band ligation for the primary prevention of bleeding for people with cirrhosis who have medium to large oesophageal varices.'
  • it should be performed at two-weekly intervals until all varices have been eradicated
  • proton pump inhibitor cover is given to prevent EVL-induced ulceration
• Transjugular Intrahepatic Portosystemic Shunt (TIPSS) may be used if the above measures are unsuccessful in preventing further episodes