Portal hypertensive bleeding: Acute management

Overview

The most important aspect of care in patients with suspected variceal or other portal hypertensive hemorrhage is adequate resuscitation and stabilization while directed diagnostic maneuvers and therapies are being coordinated (see Chapters 26 and 80 ). Although this chapter focuses on acute esophageal variceal bleeding, many of the principles and therapies may apply to other sources of portal hypertensive bleeding. Acute variceal hemorrhage is associated with a 15% to 20% mortality rate at six weeks. ^, Although evidence supports the use of endoscopy for diagnosis and treatment, insufficient resuscitation in an inappropriate environment can lead to significant periprocedural complications, while excessive resuscitation can promote bleeding. Appropriate pharmacotherapy is effective in controlling variceal hemorrhage in some patients and can be started immediately in any hospital, regardless of endoscopic staff availability.

The morbidity of patients who are seen with acute variceal hemorrhage is strongly influenced by their reason for recent decompensation (see Chapter 77 ). In most instances, early resuscitative measures, followed by pharmacotherapy and endoscopy, allow improvement in hepatic synthetic function and provide time to address more definitively the overall management of the patient and any recurrent bleeding (see Chapter 80 ). In patients with life-threatening exsanguination or who are refractory to pharmacotherapy and endoscopic intervention, balloon tamponade is a useful maneuver until the patient is stable enough for endoscopy or transjugular intrahepatic portosystemic shunting (TIPS). TIPS and other interventional radiologic procedures are being recommended earlier in the course of disease and are generally used for short-term and midterm stabilization (see Chapter 85 ) as a bridge to a more definitive therapy like transplantation. Shunt operations (see Chapters 83 and 84 ) have traditionally been reserved for individuals for whom transplantation or radiologic interventions are not an option but who have a reasonable chance of operative survival.

Emergency management

Before any diagnostic maneuvers can be performed (e.g., endoscopy), support of the circulating blood volume with adequate resuscitation is imperative. This is best achieved in an intensive care unit (ICU), although resuscitation should begin wherever the patient presents for medical attention (see Chapter 26 ). Additionally, in patients with significant bleeding or decreased consciousness, endotracheal intubation should be expedited. Isotonic crystalloid is the first replacement fluid of choice, but typed and cross-matched blood products are often needed for patients with variceal hemorrhage. Evidence supports the use of colloids versus crystalloid and packed red blood cells, with the end points of optimal hemodynamics and oxygen transport. Maintenance of hemoglobin values of approximately 7 to 9 g/dL are recommended; higher blood volumes are associated with increased portal pressures, higher rebleeding rates, and higher mortality rates. Other measures of the adequacy of resuscitation include systolic blood pressures of 90 to 100 mm Hg, central venous pressures of 9 to 16 mm Hg, and adequate urine output. When the adjusted prothrombin time (PT) is prolonged by more than three to four seconds, fresh frozen plasma is likewise recommended but may not be as beneficial as expected from the improvement in PT. Fibrinogen supplementation has been helpful in liver transplantation and may have a role. Similarly, if significant thrombocytopenia contributes to coagulopathy, platelet transfusion should commence. Recombinant factor VIIa has not been shown to benefit patients with cirrhosis with gastrointestinal (GI) hemorrhage versus standard therapy.

Complications from variceal bleeding contribute to overall morbidity and mortality related to chronic liver disease. Preventing these complications can therefore have a significant impact on the short-term mortality rate associated with variceal bleeding. Antibiotic prophylaxis has been shown to decrease variceal rebleeding and bacterial infection. ^, Systematic reviews have shown decreased mortality rates with antibiotic prophylaxis in the setting of cirrhotic GI bleeding. Based on a number of positive studies the choice of antibiotic should be dictated by patient tolerance, local antibiotic availability, and susceptibility issues and should broadly cover gram-negative rods and oral gram-positive organisms.

Controlling acute hemorrhage: Pharmacologic agents (see Chapter 80 )

Coupling pharmacologic measures and endoscopy with the initiation of preventative measures provides the most sustainable results when attempting to control acute GI hemorrhage in patients with advanced liver disease. The specific drugs are widely available, generally safe, and can be initiated as soon as variceal hemorrhage is suspected. Drugs such as somatostatin or its analogues octreotide and vapreotide work by constricting arterial and thus venous splanchnic blood flow, thereby reducing portal hypertension acutely. In randomized controlled trials comparing these vasoactive agents with other ones, including vasopressin and terlipressin, no significant differences in bleeding control were reported, although vasopressin and more recently terlipressin were associated with more adverse events. ^, ^, Currently, an initial bolus dose of octreotide 50 μg intravenously, followed by 50 μg/hr, is recommended. Duration usually extends from 72 hours to five days, and recurrent bleeding should be treated with an additional bolus dose. Only octreotide and vasopressin are currently available in the United States.

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