Lab Studies:
 

• Complete blood count: Results may show anemia, leucopenia, and thrombocytopenia in patients with cirrhosis. Anemia may be secondary to bleeding, nutritional deficiencies, or bone marrow suppression secondary to alcoholism. Many patients with portal hypertension have some degree of hypersplenism. The hematocrit value may be low in patients with upper abdominal bleeding.

• Type and crossmatch blood and order 6 units of packed red blood cells.

• Prothrombin time: Because the coagulation factors involved in this test are synthesized by the liver, impairment of the liver function may result in a prolonged prothrombin time.

• Liver function tests: A mild elevation of the plasma activity of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) may occur in cirrhosis, although activity may be normal.

• Blood urea, creatinine, and electrolytes: Blood urea and creatinine levels may be elevated in patients with esophageal bleeding. Drug treatment, cirrhosis, ascites, and blood loss may contribute to changes in the serum electrolytes of these patients.

• Arterial blood gas and pH measurements

• Hepatic serology helps in the assessment of the cause of cirrhosis.

Imaging Studies:
 

• Ultrasound of the upper abdomen may be indicated, especially if biliary obstruction or liver cancer is suspected.

Other Tests:
 

• Rectal examination: Obtain a stool sample for visual inspection. A black, soft, tarry stool on the gloved examining finger suggests upper GI bleeding.

Procedures:
 

• Endoscopy is required at an early stage to formulate the management plan. If active variceal bleeding or an adherent clot is observed, variceal hemorrhage can be diagnosed confidently. The presence of variceal red color signs (eg, cherry red spots, red whale markings, blue varices) indicates an increased risk of further bleeding.

Medical Care:

• Esophageal varices with no history of bleeding

• Patients with esophageal varices and no prior history of variceal hemorrhage should be treated with nonselective beta-adrenergic blockers (eg, propranolol, nadolol, timolol), provided that the use of beta-blockers is not contraindicated (eg, because of insulin-dependent diabetes mellitus, severe chronic obstructive lung disease, congestive heart failure).

   

• The dose of nonselective beta-blockers is determined by a 25% decrease in resting heart rate or a decrease in heart rate to 55 beats per minute or the development of adverse effects.

   

• The use of beta-blockers decreases the risk of initial variceal bleeding by approximately 45%.

   

• If contraindications to using beta-blockers exist, long-acting nitrates (eg, isosorbide 5-mononitrate) are alternatives.

   

• Treatment with beta-blockers should be continued indefinitely.

   

• The role of endoscopic sclerotherapy or variceal ligation for prevention of esophageal variceal hemorrhage is still controversial.

   

• Combined sclerotherapy and treatment with nonselective beta-blockers offer no advantages over the use of beta-blockers alone for prevention of esophageal varices hemorrhage.

• Bleeding esophageal varices

• Assess the rate and volume of bleeding. Check blood pressure and pulse with the patient in the supine position and with the patient in a sitting position.

   

• Gain venous access and obtain blood for immediate hematocrit. Obtain a type and crossmatch. Measure the platelet count and prothrombin time. Send blood for renal and liver function tests and measure serum electrolytes.

   

• Provide emergency treatment as outlined below.

• Emergency treatment
   

   

  • Promptly resuscitate and restore circulating blood volume of patients with suspected cirrhosis and variceal hemorrhage

     

  • Establish intravenous access for blood transfusion. While the blood is being crossmatched, start rapid infusion of 5% dextrose and colloid solution until blood pressure is restored and urine output is adequate.

     

  • Establish airway protection in patients with massive upper GI tract bleeding, especially if the patient is not fully conscious.

     

  • If indicated, correct clotting factor deficiencies with fresh frozen plasma, fresh blood, and vitamin K-1.

     

  • Insert a nasogastric tube to assess the severity of bleeding and to lavage gastric contents before endoscopy.

     

  • Consider pharmacologic therapy (octreotide or somatostatin) and endoscopy as soon as the patient has been resuscitated. The aim is to establish the cause and to control the bleeding.

     

  • Endoscopic therapy probably has replaced balloon tamponade as the initial therapy for variceal bleeding. Balloon tamponade now rarely is necessary, and, when it is used, it must be performed by experienced personnel because it is potentially dangerous.

• Endoscopic therapy
   

   

  • Sclerotherapy

     

    • Sclerotherapy is successful in controlling acute esophageal variceal bleeding in 80-90% of patients. Control should be obtained with 1-2 sessions. Patients continuing to bleed after 2 sessions should be considered for alternative methods to control their bleeding.

       

    • In the United States, sodium tetradecyl sulfate or sodium morrhuate generally has been used as a sclerosant, while polidocanol or ethanolamine has been more popular in Europe. Variations in the technique or the sclerosant used have not been shown to influence the outcome.

       

    • Serious complications related to sclerotherapy have been reported in 15-20% of patients, with an associated mortality rate of 2%.

       

    • Complications of sclerotherapy may include mucosal ulceration, bleeding, esophageal perforation, mediastinitis, and pulmonary complications. Long-term complications, such as esophageal stricture formation, also may occur.

     

  • Endoscopic variceal ligation (banding)

     

    • Endoscopic variceal ligation is based on the widely used technique of rubber-band ligation of hemorrhoids. The esophageal mucosa and the submucosa containing varices are ensnared, causing subsequent strangulation, sloughing, and eventual fibrosis, resulting in obliteration of the varices.

       

    • Endoscopic ligation requires placement of an opaque cylinder over the end of the endoscope. This decreases the endoscopic field of view and may allow pooling of blood. Thus, in patients with active bleeding, visualization may be impaired more with ligation than with sclerotherapy.

       

    • Recent trials have demonstrated that ligation and sclerotherapy achieved similar rates of initial hemostasis in patients whose varices were actively bleeding at the time of treatment.

       

    • Local complications are less common with ligation compared to sclerotherapy. For example, esophageal strictures were found to be less common with ligation compared to sclerotherapy. Systemic complications, such as pulmonary infections and bacterial peritonitis, were not significantly different in the 2 groups. However, a trend was observed toward a decrease in these 2 complications in patients treated with ligation.

Surgical Care:

Surgical care and therapeutic radiologic procedures for variceal hemorrhage

Approximately 5-10% of patients with esophageal variceal hemorrhage have conditions that cannot be controlled by endoscopic and/or pharmacologic treatment. Balloon tamponade (eg, Minnesota tube, Sengstaken-Blakemore tube, Linton-Nachlas tube) may be used as a temporary option in their management. Definitive salvage options may include the following:

• Surgical interventions include the following:

• Portosystemic shunt

• Devascularization (transabdominal devascularization of the lower 5 cm of the esophagus and the upper two thirds of the stomach, with staple gun transection of the lower esophagus) rarely is performed but may have a role in patients with portal and splenic vein thrombosis who are not suitable candidates for shunt procedures and who continue to have variceal bleeding despite endoscopic and pharmacologic treatment.

• Orthotopic liver transplantation is the treatment of choice in patients with advanced liver disease.

• Therapeutic radiologic procedures include the following:

• Percutaneous transhepatic embolization of gastroesophageal varices (PTE) involves catheterization of the gastric collaterals that supply blood to varices via the transhepatic route. A variety of agents had been used, with varying degrees of success in controlling acute bleeding. Generally, this procedure is less effective than endoscopic sclerotherapy for treatment of variceal hemorrhage and is much less effective compared to medical and surgical options. Thus, it should be reserved for situations in which acute variceal bleeding is not controlled by pharmaceutical treatment, endoscopic sclerotherapy, or endoscopic variceal ligation and in which contraindications for surgical management are present.

• Transjugular intrahepatic portosystemic shunts (TIPS) are an effective salvage procedure for stopping acute variceal hemorrhage after failure of medical and endoscopic treatment. However, this procedure is associated with a number of complications; 20% of patients develop encephalopathy, and 50% may occlude their shunt in 1 year. Thus, it should be considered as a bridge to subsequent liver transplantation.

Consultations: Consider early consultation with a gastroenterologist and a surgeon, particularly for patients with active bleeding from esophageal varices.

Diet: In patients with hemodynamically significant upper GI tract bleeding, a nasogastric tube should be in place for 24 hours to assist in identifying any rebleeding. Gastric lavage may be performed frequently through the nasogastric tube, and the volume and appearance of material aspirated from the stomach should be recorded. Do not allow any food by mouth.