Esophageal varices

Background

Clinical Features

History

  • Hematemesis
    • Coffee-ground emesis
  • Vomiting + retching followed by hematemesis is more likely Mallory-Weiss (esophageal)
  • Dark, tarry stools
  • Syncope or pre-syncope
  • Dyspepsia, epigastric pain or heartburn

Physical Exam

  • Tachycardia, hypotension
  • Liver disease
    • Spider angiomata, palmar erythema, jaundice, gynecomastia
  • Coagulopathy
    • Petechiae/purpura
  • Melena

Differential Diagnosis

Upper gastrointestinal bleeding

Mimics of GI Bleeding

Evaluation

Workup

  • 2 large bore IVs
  • Type and cross
  • CBC & serial hemoglobin
  • Chemistry
    • BUN/creatinine >30 suggests UGI if no history of renal failure (increased absorption/digestion of hb)
  • Coags
  • LFTs
  • Fibrinogen
  • Guiac
  • ECG (if >50 yo or if suspicious for silent MI)
  • CXR (if suspect perforation)

NG Lavage Controversy

  • Pros[1]
    • Positive aspirate proves strong evidence for an upper GI source of bleeding
    • Can assess presence of ongoing active bleeding
    • Can prepare patient for endoscopy
  • Cons[1]
    • Uncomfortable
    • Negative aspirate does not conclusively exclude upper GI source
    • Provides useful information in only minority of patients without hematemesis
    • Erythromycin 200mg IV can provide equal endoscopy conditions as lavage[2]

Management

Resuscitation

  • Place 2 large bore IVs and monitor airway status
  • Crystalloid IVF can be used for initial resuscitation but should be limited due to the dilutional anemia and dilatational coagulopathy that can result (i.e. IV fluid use in non-compressible hemorrhage)

Medications

Proton Pump Inhibitor

  • Pantoprazole or esomeprazole 80mg x 1; then 8mg/hr
    • Intermittent dosing of pantoprazole, esomeprazole, or omeprazole 40 mg IV BID not inferior to continuous infusion dosing[3]
    • Reduces the rate of re-bleeding and need for surgery if there is an ulcer, but does not reduce morbidity or mortality[4][5]
    • There is a mortality benefit in Asian patients[6]

Antibiotics

For short-term prophylaxis against SBP and bacteremia[7]

  • Ceftriaxone 1gm daily x 7 days (first line)[8]
  • OR ciprofloxacin IV or PO 500mg BID x7 days
  • Indicated for:
    • Patients with cirrhosis or history of ETOH abuse (regardless of whether bleeding is variceal or not)
    • Prior to endoscopy or as soon as possible after endoscopy

Other Medications

  • Consider octreotide (50 mcg IV bolus, then 50 mcg/hr continuous, maintained at 2-5 days)[9]
  • Consider vasopressin
    • 0.4 unit bolus, then infuse at 0.4 - 1 unit/min[10]
    • Give with IV nitroglycerin at 10 - 50 mcg/min to bolster portal hypotension and reduce vasopressin systemic effects[11]
    • Associated with many vasoconstrictive complications to include peripheral necrosis, dysrhythmias, myocardial ischemia [12]
    • Terlipressin (analog of vasopressin, available outside U.S.)
      • Alternative to vasopressin with mortality benefit
      • Given as 2mg IV q4 hrs, then decrease to 1mg IV q4 hrs until bleeding stops[13]
  • No evidence for tranexamic acid (TXA); HALT-IT trial RCT underway[14]

Blood products

Packed red blood cell transfusion

Indications:

  • Hemoglobin <7 g/dl
  • Continued active bleeding
  • Failure to improve perfusion and vital signs after infusion of 2L NS
  • Known varicele bleeding[16]

Other Blood Products

Consider initiating massive transfusion protocol

Balloon tamponade with Sengstaken-Blakemore Tube

For life-threatening hemorrhage if endoscopy is not available

  • Adverse reactions are frequent:
    • Mucosal ulceration
    • Esophageal/gastric rupture
    • Tracheal compression (consider intubation prior to balloon insertion)

Endoscopy

Should be performed at the discretion of the gastroenterologist; within 12 hrs for variceal bleeding[19]

  • Early endoscopy does not necessarily improve clinical outcomes[20]
  • Consider erythromycin 3mg/kg IV over 20-30min, 30-90min prior to endoscopy
    • Achieves endoscopy conditions equal to lavage[21]

Intubation

Protection of airway from massive aspiration, especially prior to endoscopy; does not protect against pneumonia or cardiopulmonary events[22]

NO CHRISTMAS[23]

Have bed-side push-dose pressors on hand

  • NGT (salem sump to remove stomach contents)
    • Varices not contraindication to NGT
    • Consider metoclopramide 10mg IV
  • Good pre-Oxygenation critical
  • Chest and HOB elevation to 45 degrees - consider intubating from 45 degrees to prevent gastric contents coming up
  • RSI - consider halving dosages for lost blood volume
    • Etomidate or ketamine for sedation
    • Succinylcholine and vecuronium increases LES tone
  • Intubation with strong chance for first pass
  • Slow and gentle BVM breathes at 10 breathes/min if first pass fails
  • Trendelenberg if vomiting, keeping emesis out of lungs (have many suctions available before this happens)
  • Meconium aspirator may be hooked up to ETT for large bore suction
  • Antibiotics not needed in early phase of aspiration
    • Chemical pneumonitis in first 24 hours, no bacterial pneumonia
    • Early antibiotics may predispose patient to resistant bacterial superinfection
  • SIRS-like response often occurs from aspiration, but otherwise not sepsis if there is no other concerning source or suspicion
    • May require pressors and fluids
    • Consider withholding early antibiotics, but doing the rest of the sepsis treatments

Disposition

  • Admission

See Also

References

  1. 1.0 1.1 Aljebreen AM et al. Nasogastric aspirate predicts high-risk endoscopic lesions in patients with acute upper-GI bleeding. Gastrointest Endosc. 2004;59(2):172-178.
  2. Huang ES et al. Impact of nasogastric lavage on outcomes in acute GI bleeding. Gastrointest Endosc. 2011;74(5):971-980.
  3. Sachar H, Vaidya K, Laine L. Intermittent vs continuous proton pump inhibitor therapy for high-risk bleeding ulcers: a systematic review and meta-analysis. JAMA Intern Med. 2014;174(11):1755.
  4. Leontiadis GI et al. Proton pump inhibitor treatment for acute peptic ulcer bleeding. Cochrane Database Syst Rev. 2004(3):CD002094.
  5. Sreedharan A et al. Proton Pump Inhibitor Treatment Initiated Prior to Endoscopic Diagnosis in Upper Gastrointestinal Bleeding (Review). Cochrane Database Syst Rev 2010; (7): CD005415. PMID: 20614440
  6. Singh M. Proton pump inhibitors (PPIs) given for acute peptic ulcer bleeding 2013; bleeding/
  7. Lee YY et al. Role of prophylactic antibiotics in cirrhotic patients with variceal bleeding. World J Gastroenterol. 2014 Feb 21; 20(7): 1790–1796.
  8. Fernandez J, Ruiz dA, Gomez C, et al. Norfloxacin vs ceftriaxone in the prophylaxis of infections in patients with advanced cirrhosis and hemorrhage. Gastroenterology. 2006;131:1049–1056.
  9. Augustin S et al. Acute esophageal variceal bleeding: Current strategies and new perspectives. World J Hepatol. 2010 Jul 27; 2(7): 261–274.
  10. Ioannou G, Doust J, Rockey DC. Terlipressin for acute esophageal variceal hemorrhage. Cochrane Database Syst Rev 2003:CD002147.
  11. Tsai YT, Lay CS, Lai KH, et al. Controlled trial of vasopressin plus nitroglycerin vs. vasopressin alone in the treatment of bleeding esophageal varices. Hepatology 1986; 6:406.
  12. GI Bleeding: An Evidence-Based ED Approach. EB Medicine. http://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=75&seg_id=1507
  13. Ioannou G, Doust J, Rockey DC. Terlipressin for acute esophageal variceal hemorrhage. Cochrane Database Syst Rev 2003:CD002147.
  14. Roberts I et al. HALT-IT - tranexamic acid for the treatment of gastrointestinal bleeding: study protocol for a randomised controlled trial. Trials. 2014; 15: 450.
  15. Dworzynski K et al. Management of acute upper gastrointestinal bleeding: summary of NICE guidance. BMJ. 2012;344:e3412.
  16. Intagliata NM, et al. Management of disordered hemostasis and coagulation in patients with cirrhosis. Clinical Liver Disease. 2014; 3(6):114-117.
  17. Makris M, et al. Warfarin anticoagulation reversal: management of the asymptomatic and bleeding patient. J Thromb Thrombolysis. 2010; 28:171–181.
  18. Intagliata NM, et al. Management of disordered hemostasis and coagulation in patients with cirrhosis. Clinical Liver Disease. 2014; 3(6):114-117.
  19. Kim YD. Management of acute variceal bleeding. Clin Endosc. 2014; 47(4):308–314.
  20. Sarin N et al. Time to endoscopy and out- comes in upper gastrointestinal bleeding. Can J Gastroenterol. 2009;23(7):489-493.
  21. Pateron D, et al. Erythromycin infusion or gastric lavage for upper gastrointestinal bleeding: a multicenter randomized controlled trial. Ann Emerg Med. 2011; 57(6):582-589.
  22. Rudolph SJ et al. Endotracheal intubation for airway protection during endoscopy for severe upper GI hemorrhage. Gastrointest Endosc. 2003 Jan;57(1):58-61.
  23. Weingart S. EMCrit Podcast 5 – Intubating the Critical GI Bleeder. June 2009. http://emcrit.org/podcasts/intubating-gi-bleeds/

Authors:

Ross Donaldson