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First things first!
Admit to Intensive Care Unit
Resuscitate!
-
Goal Hb 7 - 9 g/dL
- Overtransfusion is associated w/
risk of adverse events (MI & TACO)
Consider intubation & for airway protection
- Slightin risk of pneumonia
2/
Admit to Intensive Care Unit
Resuscitate!
-
Goal Hb 7 - 9 g/dL- Overtransfusion is associated w/
risk of adverse events (MI & TACO)Consider intubation & for airway protection
- Slight
in risk of pneumonia2/
Start vasoactive drugs:
· Selectively constrict mesenteric arterioles
·
portal blood flow
·the rate of active bleeding
· Make EGD easier for diagnosis & treatment
Meds:
· Octreotide (50 mcg push, 50 mcg/hr x 48-72 hours)
· Vasopressin
· Somatostatin
· Terlipressin
3/
· Selectively constrict mesenteric arterioles
·
portal blood flow·
the rate of active bleeding· Make EGD easier for diagnosis & treatment
Meds:
· Octreotide (50 mcg push, 50 mcg/hr x 48-72 hours)
· Vasopressin
· Somatostatin
· Terlipressin
3/
Start Proton Pump Inhibitor
· Unclear role (no trial data)
· Standard of care for other causes of GI Bleed
· @UNCGastro uses pantoprazole 40mg IV BID
Consider erythromycin:
· Prokinetic agent
· Administered ≤ 2 hrs before EGD
·visualization
·need for repeat EGD
4/
· Unclear role (no trial data)
· Standard of care for other causes of GI Bleed
· @UNCGastro uses pantoprazole 40mg IV BID
Consider erythromycin:
· Prokinetic agent
· Administered ≤ 2 hrs before EGD
·
visualization·
need for repeat EGD4/
Antibiotic prophylaxis:
· IV ceftriaxone 1 g q24 hours x 7 days
· Norfloxacin 400 mg BID x 7 days
· Ciprofloxacin 400 mg BID x 7 days
rate of rebleeding
Hepatol Int. 2008 Dec; 2(4):429-39.
5/
· IV ceftriaxone 1 g q24 hours x 7 days
· Norfloxacin 400 mg BID x 7 days
· Ciprofloxacin 400 mg BID x 7 days
rate of rebleedingHepatol Int. 2008 Dec; 2(4):429-39.
5/
Now it's finally time for endoscopy!
Goal: EGD ≤ 12 hrs of presentation
Banding:
· Standard of care
· Initial target: actively bleeding varix, fibrin plug, red wale
· Addt'l bands placed at EG junction (if safe)
· Apply bands in spiral pattern up to ~28cm from incisors
6/
Goal: EGD ≤ 12 hrs of presentation
Banding:
· Standard of care
· Initial target: actively bleeding varix, fibrin plug, red wale
· Addt'l bands placed at EG junction (if safe)
· Apply bands in spiral pattern up to ~28cm from incisors
6/
Sclerotherapy:
· Injection of sclerosant into varix or paravariceal tissue
· Sodium tetradecyl sulfate or cyanoacrylate
· High complication rate (bacteremia, PE)
· Second line therapy
7/
· Injection of sclerosant into varix or paravariceal tissue
· Sodium tetradecyl sulfate or cyanoacrylate
· High complication rate (bacteremia, PE)
· Second line therapy
7/
Following hemostasis
· Initiate non-selective beta blocker
· Consider oral PPI (pantoprazole 40 mg daily x 2 weeks) torisk of post-banding ulcer (shown) bleed
· Repeat endoscopy in 1 week with repeat banding if needed
· Serial endoscopy until total obliteration
8/
· Initiate non-selective beta blocker
· Consider oral PPI (pantoprazole 40 mg daily x 2 weeks) to
risk of post-banding ulcer (shown) bleed· Repeat endoscopy in 1 week with repeat banding if needed
· Serial endoscopy until total obliteration
8/
What about when these measures fail??
Can consider a self-expandable metal stent:
· High rate of successful placement
· Hemostasis rate of 96%
· Ineffective for bleeding gastric varices
AEs:
· Rebleeding after removal (16%)
· Stent migration (28%)
Bridge to TIPS/OLT
9/
Can consider a self-expandable metal stent:
· High rate of successful placement
· Hemostasis rate of 96%
· Ineffective for bleeding gastric varices
AEs:
· Rebleeding after removal (16%)
· Stent migration (28%)
Bridge to TIPS/OLT
9/
Hemostatic Powder
3 commercially available:
· Hemospray
· EndoClot
· Ankaferd Bloodstopper(great name!)
Moisture → mechanical barrier to cover bleeding site
~24 hours layer sloughs off
Approved for tumor bleeding and lower GI bleeding
Used off-label for variceal bleeding
10/
3 commercially available:
· Hemospray
· EndoClot
· Ankaferd Bloodstopper(great name!)
Moisture → mechanical barrier to cover bleeding site
~24 hours layer sloughs off
Approved for tumor bleeding and lower GI bleeding
Used off-label for variceal bleeding
10/
Finally, if all else fails:
Blakemore Sengstaken / Minnesota Tube
· Created in 1949
· Temporize while awaiting TIPS/OLT
· Useful in EV & GV (except IGV2)
· High risk for aspiration (10%)
· Minnesota tube has an esophageal suction port
11/
Blakemore Sengstaken / Minnesota Tube
· Created in 1949
· Temporize while awaiting TIPS/OLT
· Useful in EV & GV (except IGV2)
· High risk for aspiration (10%)
· Minnesota tube has an esophageal suction port
11/
The original publication for the Blakemore tube is the only paper I've ever read that includes a recipe (important to keep feeding patients while tamponade in place)
12/
12/
I'll stop there for today.
Tomorrow I will cover TIPS /BRTO placement which is can salvage uncontrolled variceal hemorrhage.
Stay safe and keep learning!
/END/
Tomorrow I will cover TIPS /BRTO placement which is can salvage uncontrolled variceal hemorrhage.
Stay safe and keep learning!
/END/
