Esophageal varices

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Background

Layers of the GI track: the mucosa, submucosa, muscularis, and serosa.

Sites of Portalcaval Anastomosis

Clinical presentations of portal hypertension include:

Region Name of clinical condition Portal circulation Systemic circulation
Esophageal Esophageal varices Esophageal branch of left gastric vein Esophageal branches of azygos vein
Rectal Rectal varices Superior rectal vein Middle rectal veins and inferior rectal veins
Paraumbilical Caput medusae Paraumbilical veins Superficial epigastric vein
Retroperitoneal Splenorenal shunt Splenic vein Renal vein, suprarenal vein, paravertebral vein, and gonadal vein
(no clinical name) Right colic vein, middle colic vein, left colic vein Retroperitoneal veins of Retzius
Intrahepatic Hepatic pseudolesions Perihepatic veins of Sappey Superior epigastric vein
Patent ductus venosus Left branch of portal vein Inferior vena cava

A dilated inferior mesenteric vein may or may not be related to portal hypertension. Other areas of anastomosis include the bare area of the liver as it connects to the diaphragm, the posterior portion of the gastrointestinal tract as it touches the posterior abdominal wall, the posterior surface of the pancreas, and the inferior part of the esophagus.

Clinical Features

Gastroscopy image of esophageal varices with prominent cherry-red spots and "wale" signs.
Esophageal varices seven days after banding, showing ulceration at the site of banding.

History

Physical Exam

Differential Diagnosis

Upper gastrointestinal bleeding

Mimics of GI Bleeding

Evaluation

Pronounced esophageal varices extending superiorly cranially in liver cirrhosis. Left 3 axial slices, right sagittal.
Oesophagusvarizen 02.jpg

Workup

  • 2 large bore IVs (or sheath introducer)
  • 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
    • More useful for diagnosing chronic occult bleeding (it could be positive for up to 2 weeks after an acute bleed)
    • False-positive: vitamin C, red meat, methylene blue, bromide preparations, turnips, horseradish
  • ECG (if >40 yo or if suspicious for silent MI, especially from demand ischemia)
  • 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]

Diagnosis

  • Endoscopy frequently required for definitive diagnosis of underlying etiology

Management

Resuscitation

  • Place 2 large bore IVs (or sheath introducer/rapid infusion catheter) and monitor airway status
  • Crystalloid IVF can be used for initial resuscitation but should be limited due to the dilutional anemia and 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 in patients with concern for variceal bleeding)[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]
  • tranexamic acid (TXA) initially thought to help, NNT = 30, no one harmed[14]; but HALT-IT trial RCT[15] found it did not reduce death from GI bleeding[16]

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[18]

Other Blood Products

Consider initiating massive transfusion protocol

Other Interventions

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[21]

  • Early endoscopy does not necessarily improve clinical outcomes[22]
  • Consider erythromycin 3mg/kg IV over 20-30min, 30-90min prior to endoscopy
    • Achieves endoscopy conditions equal to lavage[23]

Intubation

Protection of airway from massive aspiration, especially prior to endoscopy; does not protect against pneumonia or cardiopulmonary events[24]

NO CHRISTMAS[25]

Have bed-side push-dose pressors on hand

  • NGT (salem sump to remove stomach contents)
    • Varices not contraindication to NGT
    • Consider metoclopramide 10mg IV
      • Increases tone of lower esophageal sphincter[26]
  • 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 sedation dosages for lost blood volume
  • Intubation with strong chance for first pass
  • Slow and gentle BVM breaths at 10 breaths/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, not 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. Beyda, R., & Johari, D. (2019). Tranexamic acid for upper gastrointestinal bleeding. Academic Emergency Medicine. 2019 Oct;26(10):1181-1182
  15. 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.
  16. The HALT-IT Trial Collaborators. (2020). Effects of a high-dose 24-h infusion of transexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. Lancet. 2020; 395:1927-36
  17. Dworzynski K et al. Management of acute upper gastrointestinal bleeding: summary of NICE guidance. BMJ. 2012;344:e3412.
  18. Intagliata NM, et al. Management of disordered hemostasis and coagulation in patients with cirrhosis. Clinical Liver Disease. 2014; 3(6):114-117.
  19. Makris M, et al. Warfarin anticoagulation reversal: management of the asymptomatic and bleeding patient. J Thromb Thrombolysis. 2010; 28:171–181.
  20. Intagliata NM, et al. Management of disordered hemostasis and coagulation in patients with cirrhosis. Clinical Liver Disease. 2014; 3(6):114-117.
  21. Kim YD. Management of acute variceal bleeding. Clin Endosc. 2014; 47(4):308–314.
  22. Sarin N et al. Time to endoscopy and out- comes in upper gastrointestinal bleeding. Can J Gastroenterol. 2009;23(7):489-493.
  23. 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.
  24. Rudolph SJ et al. Endotracheal intubation for airway protection during endoscopy for severe upper GI hemorrhage. Gastrointest Endosc. 2003 Jan;57(1):58-61.
  25. Weingart S. EMCrit Podcast 5 – Intubating the Critical GI Bleeder. June 2009. http://emcrit.org/podcasts/intubating-gi-bleeds/
  26. Mikami H, Ishimura N, Fukazawa K, et al. Effects of Metoclopramide on Esophageal Motor Activity and Esophagogastric Junction Compliance in Healthy Volunteers. J Neurogastroenterol Motil. 2016;22(1):112-117. doi:10.5056/jnm15130