Variceal haemorrhage



Epidemiology
Clinical features
Management


Epidemiology

  • Incidence: 20.00 cases per 100,000 person-years
  • Peak incidence: 60-70 years
  • Sex ratio: 1:1
<1 1-5 6+ 16+ 30+ 40+ 50+ 60+ 70+ 80+

Clinical features

Management

Acute treatment of variceal haemorrhage
  • ABC: patients should ideally be resuscitated prior to endoscopy
  • correct clotting: FFP, vitamin K
  • vasoactive agents: terlipressin is currently the only licensed vasoactive agent and is supported by NICE guidelines. It has been shown to be of benefit in initial haemostasis and preventing rebleeding. Octreotide may also be used although there is some evidence that terlipressin has a greater effect on reducing mortality
  • prophylactic antibiotics have been shown to reduce mortality in patients with liver cirrhosis. Quinolones are typically used. NICE support this in their 2016 guidelines: 'Offer prophylactic intravenous antibiotics for people with cirrhosis who have upper gastrointestinal bleeding.'
  • endoscopy: endoscopic variceal band ligation is superior to endoscopic sclerotherapy. NICE recommend band ligation
  • Sengstaken-Blakemore tube if uncontrolled haemorrhage
  • Transjugular Intrahepatic Portosystemic Shunt (TIPSS) if above measures fail

Prophylaxis of variceal haemorrhage
  • propranolol: reduced rebleeding and mortality compared to placebo
  • endoscopic variceal band ligation (EVL) is superior to endoscopic sclerotherapy. It should be performed at two-weekly intervals until all varices have been eradicated. Proton pump inhibitor cover is given to prevent EVL-induced ulceration. This is supported by NICE who recommend: 'Offer endoscopic variceal band ligation for the primary prevention of bleeding for people with cirrhosis who have medium to large oesophageal varices.'