see also:

• upper GIT bleeding
• cirrhosis
• portal hypertension
• AFTB Lectures - oesophageal varices (2016)

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

• 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.

• 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