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Management of variceal bleeding

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... stricture reduction in rebleeding with Octreotide infusion + endoscopic banding Endoscopic band ligation Failure of endoscopic therapy Within 48 hrs from ... – PowerPoint PPT presentation

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Title: Management of variceal bleeding


1
Management of variceal bleeding
  • Dr. Bennet Rajmohan, MRCSEd, MRCS (Eng)
  • Consultant General Surgeon

2
Introduction
  • 30 of patients with cirrhosis develop portal
    hypertension
  • 30 of patients with portal hypertension will
    bleed from varices within 2 years
  • Incidence of varices in cirrhotics 8 / year

3
Active variceal bleed
  • 1 of 3 major complications of portal hypertension
    others ? ascites encephalopathy
  • 1/3rd of all deaths related to cirrhosis
  • Bleed occurs earlier in course of cirrhosis or
    with normal liver ? wider treatment options than
    for ascites encephalopathy

4
Overview
  • Treatment of an active bleed
  • Prediction of patients at risk
  • Prophylaxis against a first bleed
  • Prevention of rebleeding

5
Definitions
  • Time zero time of admission to hospital
  • Clinically significant bleeding
  • 2 units of blood or more within 24 hrs of time
    zero
  • systolic BP lt100 mmHg
  • postural systolic change of gt20 mmHg
  • and/or a pulse rate gt100/min at time zero

6
Treatment of an active bleed
7
GENERAL PRINCIPLES
  • 3 primary goals
  • Haemodynamic resuscitation
  • Prevention treatment of complications
  • Treatment of bleeding

8
Hemodynamic resuscitation 
  • Packed cells and clotting factors
  • Platelet transfusions, if lt 50,000/mm3 active
    bleeding
  • Avoid volume overload ? risk of rebound portal
    hypertension and rebleed

9
Recombinant factor VIIa 
  • Coagulopathy in severely volume overloaded ? FFPs
    inadequate
  • At least 2 RCTs no clear benefit of recombinant
    factor VII
  • awaits further clarification

10
Prevention management of complications
11
Complications ? death
  1. Aspiration pneumonia
  2. Sepsis
  3. Hepatic encephalopathy
  4. Renal failure

12
Aspiration 
  • Massive bleeding Endotracheal intubation to
    protect airway ? use unclear
  • NG tube unclear
  • Can decompress stomach for subsequent endoscopy

13
2. Sepsis
  • Bacterial infections 20 of cirrhotics
    hospitalized with GI bleed
  • Additional 50 develop infection in hospital
  • Most common
  • UTI (12 29)
  • SBP (7 23)
  • respiratory (6 10)
  • primary bacteraemia (4 11)

14
Antibiotics
  • overall ? in infectious complications
  • possibly ? mortality
  • ? risk of recurrent bleeding
  • IV Ciprofloxacin x 7 days or Oral Norfloxacin
    (400mg bd)
  • Advanced cirrhosis, IV Ceftriaxone (1G od)

15
3. Hepatic encephalopathy
  • aggressive search for potentially reversible
    factors
  • GI bleed
  • hypokalemia
  • metabolic alkalosis
  • Lactulose or L Ornithine

16
4. Renal failure 
  • acute tubular necrosis or hepatorenal syndrome
  • minimized by
  • appropriate volume replacement
  • avoid aminoglycosides
  • avoid mismatched transfusions

17
Other measures
  • Alcoholics
  • Thiamine
  • monitor for withdrawal symptoms
  • Nutritionally depleted subjects
  • hypophosphatemia hypokalemia
  • dextrose infusions raise serum insulin ? drives
    both phosphate potassium into cells

18
Treatment of bleeding
19
Treatment
  • Hepatic vein pressure gradient gt12mmHg
  • 50 variceal bleed stops spontaneously vs gt 90
    in other forms of UGI bleed
  • Options
  • Pharmacotherapy
  • Endoscopy
  • Balloon tamponade
  • Surgery

20
Pharmacotherapy
  • Terlipressin
  • synthetic vasopressin analog released in slow
    sustained manner, 8th hrly doses
  • sustained effect on portal pressure blood flow
    vs transient effect with octreotide
  • Only drug which reduces mortality

21
Pharmacotherapy
  • Somatostatin
  • 250 mcg bolus f/b 250 mcg/h by IV infusion x 5
    days
  • Octreotide
  • More easily available
  • 50 mcg bolus f/b 50 mcg/h by IV infusion x 5 days

22
Endoscopic Treatment 
  • Endoscopist experience and expertise
  • Grade of varices
  • Grade 1 Small, straight varices
  • Grade 2 tortuous varices occupying lt1/3rd of
    lumen
  • Grade 3 Large, coil-shaped varices occupying gt
    1/3rd of lumen

23
Endoscopic Sclerotherapy
  • injection of sclerosant into varices
  • Complications
  • Local ulceration, bleeding, dysmotility,
    stricture portal hypertensive gastropathy
  • Regional esophageal perforation mediastinitis

24
Endoscopic band ligation 
  • placing small elastic bands around varices in
    distal 5cm of oesophagus
  • complications significantly lower
  • much lower rate of oesophageal stricture
  • reduction in rebleeding with Octreotide infusion
    endoscopic banding

25
(No Transcript)
26
Endoscopic band ligation
27
Failure of endoscopic therapy
  • Within 48 hrs from time zero
  • Reasons
  • Spurting varices
  • High Child-Pugh score
  • High hepatic venous pressure gradient
  • Infection
  • Portal vein thrombosis

28
Failure of therapy
  • Within the first 6 hrs from time zero
  • gt 4 units blood
  • an inability to increase systolic BP by 20 mmHg
    or to 70 mmHg
  • and/or an inability to attain a pulse rate
    lt100/min

29
Failure of therapy
  • After 6 hrs from time zero
  • occurrence of haematemesis
  • ?systolic BP of gt 20 mmHg
  • ?pulse rate by 20/min from 6 hr time point
  • 2 units or more of blood to keep Hb around 9 g/dL

30
Early rebleeding
  • gt 48 hrs from time zero but within 6 wks
  • Reasons
  • Severe initial bleeding
  • Overly aggressive volume resuscitation
  • Infection
  • High hepatic venous pressure gradient
  • Complications of endoscopic therapy
  • Renal failure

31
Late rebleeding
  • After 6 wks
  • Reasons
  • High Child-Pugh score
  • Large variceal size
  • Continued alcohol use
  • Hepatocellular carcinoma

32
What to do when endoscopic treatment fails
  • 10 to 20 of emergencies
  • No data to support use of higher doses of
    octreotide or somatostatin
  • Options
  • 2nd attempt at endoscopic haemostasis
  • Balloon tamponade
  • TIPS
  • Surgery

33
BALLOON TAMPONADE 
  • Sengstaken-Blakemore tube
  • 250 cc gastric balloon, an esophageal balloon and
    a gastric suction port
  • Initial control 30 to 90 of patients
  • Major complications approx 14
  • Risk of rebleed on deflation
  • Temporary stabilization before more definitive
    treatment

34
Sengstaken tube
35
TIPS
  • Transjugular intrahepatic portosystemic shunt
  • Like side-to-side surgical portacaval shunts
    without GA or major surgery
  • active bleed failed endoscopic medical
    treatment
  • Poor surgical candidates
  • 60 90 1-month survival vs 10 20 in surgery

36
  • TIPS

37
Surgery
  • Ideal surgical patient
  • well preserved liver function who fails emergent
    endoscopic treatment and has no complications
    from bleeding or endoscopy
  • Distal splenorenal shunt (Warren shunt)
  • effective therapy for active variceal haemorrhage
    in experienced hands

38
Surgery (contd)
  • Esophageal transection
  • effective as sclerotherapy
  • troublesome suture line bleeding
  • varices recur after variable period of time

39
Surgery (contd)
  • Sugiura procedure
  • Controls bleed in 70 90
  • Entire greater curve, distal 7cms of oesophagus
    upper 2/3rds of lesser curve devascularised
  • Splenectomy not necessary
  • Oesophageal transection not necessary already
    sclero / banded

40
Gastric varices
  • GLUE (N-butyl-cyanoacrylate, isobutyl-2-cyanoacryl
    ate) or thrombin more effective than sclero or
    banding
  • TIPS bleeding control rates gt 90
  • balloon-occluded injection sclerotherapy
  • Surgery

41
Endoscopic glue
42
Prediction of patients at risk
  • Varices at OG junction, gastric fundus
  • Higher grade of oeso.varices
  • "red signs at endoscopy
  • Higher Child-Pugh score
  • h/o previous variceal bleed
  • Higher variceal pressure (endoscopic gauge)

43
Prophylaxis against first bleed(Primary
Prophylaxis)
  • all cirrhotics diagnostic endoscopy
  • document varices
  • determine risk of bleed
  • Nonselective ß blockers
  • lower portal pressure
  • reduce risk of first bleed
  • Endoscopic banding
  • Intolerance to ß blockers
  • Contraindications to ß blockers (asthma, renal
    failure)
  • Higher varix grade

44
Prevention of rebleed (Secondary Prophylaxis)
  • 70 risk within 1 yr of bleed
  • 70 of all untreated patients die within 1 yr of
    initial bleed
  • Options
  • endoscopic sclero / band ligation
  • beta blockers and/or oral nitrates
  • TIPS (Child A or B)
  • Surgery (Child A)

45
Prevention of rebleed (Secondary Prophylaxis)
  • Beta blockers plus band ligation Combination
    therapy, better at preventing rebleed
  • TIPS lesser rebleed, more expensive, more
    encephalopathy, same survival
  • Surgery distal splenorenal shunt, better
    bleeding control but less survival, sclerotherapy
    better

46
Prevention of rebleed(Secondary Prophylaxis)
  • Orthotopic Liver transplantation 
  • only treatment which corrects portal hypertension
    and liver failure
  • long wait for an organ
  • Survival ? 80 to 90 at 1 yr to
  • ? 60 at 5 yrs

47
THANKS
48
Child Pugh score
Parameter 1 point 2 points 3 points
S. Bilirubin (mg/dl) lt 2 2 3 gt 3
Albumin (g/dl) gt 3.5 2.8 3.5 lt 2.8
Prothrombin time ( ? secs) 1 3 4 6 gt6
Ascites None Slight Moderate
Encephalopathy None Grade 1 2 3 4
A 5 to 6 points B 7 to 9
C 10 to 15
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