Day 8 of #DistanceMedEd

What do we do when varices bleed?

1/
First things first!

Admit to Intensive Care Unit

Resuscitate!
-https://abs.twimg.com/emoji/v2/... draggable="false" alt="🩸" title="Drop of blood" aria-label="Emoji: Drop of blood">Goal Hb 7 - 9 g/dL
- Overtransfusion is associated w/ https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Upwards arrow" aria-label="Emoji: Upwards arrow">risk of adverse events (MI & TACO)

Consider intubation & for airway protection
- Slight https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Upwards arrow" aria-label="Emoji: Upwards arrow">in risk of pneumonia

2/
Start vasoactive drugs:
· Selectively constrict mesenteric arterioles
· https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬇️" title="Downwards arrow" aria-label="Emoji: Downwards arrow">portal blood flow
· https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬇️" title="Downwards arrow" aria-label="Emoji: Downwards arrow">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 vasoactive drugs:· Selectively constrict mesenteric arterioles· https://abs.twimg.com/emoji/v2/... draggable=portal blood flow· https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬇️" title="Downwards arrow" aria-label="Emoji: Downwards arrow">the rate of active bleeding· Make EGD easier for diagnosis & treatmentMeds:· Octreotide (50 mcg push, 50 mcg/hr x 48-72 hours)· Vasopressin· Somatostatin· Terlipressin3/" title="Start vasoactive drugs:· Selectively constrict mesenteric arterioles· https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬇️" title="Downwards arrow" aria-label="Emoji: Downwards arrow">portal blood flow· https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬇️" title="Downwards arrow" aria-label="Emoji: Downwards arrow">the rate of active bleeding· Make EGD easier for diagnosis & treatmentMeds:· Octreotide (50 mcg push, 50 mcg/hr x 48-72 hours)· Vasopressin· Somatostatin· Terlipressin3/" class="img-responsive" style="max-width:100%;"/>
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
· https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Upwards arrow" aria-label="Emoji: Upwards arrow">visualization
· https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬇️" title="Downwards arrow" aria-label="Emoji: Downwards arrow">need for repeat EGD

4/
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

https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬇️" title="Downwards arrow" aria-label="Emoji: Downwards arrow">rate of rebleeding

Hepatol Int. 2008 Dec; 2(4):429-39.

5/
Now it& #39;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& #39;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/
Following hemostasis
· Initiate non-selective beta blocker
· Consider oral PPI (pantoprazole 40 mg daily x 2 weeks) to https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬇️" title="Downwards arrow" aria-label="Emoji: Downwards arrow">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/
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/
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/
The original publication for the Blakemore tube is the only paper I& #39;ve ever read that includes a recipe (important to keep feeding patients while tamponade in place)

12/
I& #39;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/
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