Variceal bleeding: Current issues

Abstract

Portal hypertension (PHT) is a serious sequel of liver cirrhosis. Eventually, varices develop, grow in size, and bleed. Several diagnostic modalities including transient elastography (TE), capsule endoscopy, CT scanning, and platelets count/spleen diameter ratio (PSR) have recently been introduced. Predictors of bleeding include large varices, red signs, severe liver disease, and hepatic venous pressure gradient (HVPG)12 mmHg. Oral nonselective (NSBB) are recommended for primary prophylaxis in patients with medium-to-large size esophageal varices (EV) that have not bled. Patients with acute variceal bleeding (AVB) should be resuscitated and managed in an intensive care unit. Vasoactive drugs should be started immediately aimed at a better control of bleeding and facilitation of a subsequent endoscopy. Terlipressin controls bleeding and mortality and is considered as the drug of choice. Antibiotic prophylaxis significantly improves survival compared with placebo. Early diagnostic and therapeutic endoscopy in patients with major bleeding enhances control of bleeding, reduces risks of rebleeding and mortality. The use of erythromycin prior to endoscopy clears the stomach, reduces the need for second endoscopy and blood transfusion, and shortens the length of hospital stay. Restricted transfusion strategy prevents portal pressure rise and improves the survival rate. The current recommendation is to treat AVB with a combination of vasoactive agent, EVL, and antibiotics. All patients who survive an episode of AVB should undergo secondary prophylaxis. Transjugular intrahepatic portosystemic shunt (TIPS) using covered stent represents the first-choice rescue treatment. Early TIPS insertion significantly reduces treatment failure, rebleeding, and mortality. Also, insertion of esophageal SX-Ella Danis stent in patients with refractory VB effectively controls bleeding. The data required for this review were obtained mainly through PubMed and Google search.