Day 8 of #DistanceMedEd

What do we do when varices bleed?

1/

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
- Slight in risk of pneumonia

2/

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/

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/

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/

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/

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 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've ever read that includes a recipe (important to keep feeding patients while tamponade in place)

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/