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oesophageal_varices

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oesophageal varices

Introduction

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:
    • 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
oesophageal_varices.txt · Last modified: 2018/08/11 18:28 (external edit)