Table of Contents

Introduction
Epidemiology
Mx in ED

oesophageal varices

see also:

Introduction

oesophageal varices are primarily caused by portal hypertension which most commonly results from cirrhosis
these may cause significant and life threatening upper GIT bleeding

Epidemiology

50% of patients with cirrhosis have varices
85% of those with Child-Pugh C severity have varices
it is the most common cause of upper GIT bleeding in patients with chronic liver disease
these patients have a 30-80% 1 yr mortality of which 15-30% of deaths occur with the 1st bleed
around half of those who have banding or sclerotherapy for Rx of the varices will re-bleed.

Mx in ED

assuming no Advanced care Directive otherwise, move to a resuscitation area and resuscitate:
- large bore IV access x 2
- FBE, U&E, LFTs, lipase, Xmatch, coagulation profile
- correct volume loss, preferably with blood - may need to activate the hospital's massive blood transfusion procedure (MTP)
- commence iv octreotide as this has 80% success in decreasing the bleeding but does not decrease mortality, nevertheless it does buy time for endoscopy
  - 50 μg bolus, then 25-50 μg/hr IV
- early referral to gastroenterology for urgent endoscopy
- reduce portal hypertension options include:
  - Terlipressin (Glypressin) 2 mg 6-hrly, or,
  - vasopressin
  - and, or GTN
- all patients with cirrhosis and upper GIT bleed should be given antibiotics early, such as either:
  - norfloxacin 400 mg orally bd, or,
  - ciprofloxacin 400mg bd IV, or,
  - ceftriaxone 1g daily IV
- if inadequate response, may require resorting to heroic options (there will still be up to an 80% 30 day mortality) such as:
  - intubation
  - balloon tamponade of varices via a Sengstaken-Blakemore tube
    - however, this is associated with significant complication rate (around 25%) and 50% of patients re-bleed on its removal
  - Transjugular intrahepatic portosystemic shunt (TIPS)
  - emergency direct portacaval shunt (EPCS)
  - emergency oesophageal resection