Suspected Variceal Bleeding

Assessment

1. Check pulse and BP (including postural drop if not hypotensive).
2. Assess for stigmata of chronic liver disease.
3. Check FBC, coagulation, U&Es and LFTs.
4. Cross-match 6units of blood.
5. Print off and follow the decompensated liver disease care bundle – click link below

Management

1. The following management plan is for all patients with suspected variceal haemorrhage if there is evidence of chronic liver disease and of a significant gastrointestinal bleed,  before a diagnosis of variceal bleed is confirmed.
2. Resuscitate using ABCDE as appropriate and transfer to Critical Care.
3. If patient is shocked (pulse >100bpm, systolic BP <100mmHg and evidence of bleeding) should have a urinary catheter and consideration of central line.
4. In all cases where there has been a large bleed, cardiovascular instability, depressed conscious level or airway compromised EARLY involvement of consultant physician, consultant surgeon and consultant anaesthetist is important.
5. Correct any clotting and platelet abnormality (discuss with haematology).
6. Resuscitate with blood or crystalloid aiming to maintain Hb >70g/L, pulse <100bpm, systolic BP >90, CVP 8–10cm and urine output >30ml/hour. Resuscitation and transfusion requirements also depend on patient’s age and co-morbidities.
7. Start appropriate drug therapy – see below.
8. If ascites is present perform an ascitic tap.
9. If stable should be listed for urgent endoscopy.
10. If unstable contact Critical Care first and then the Endoscopist. Sengstaken tubes are best done in theatre with Airway protection and Image intensifier guidance unless it is a peri arrest salvage attempt situation.  Click here for more information on Sengstaken/Minnesota Tubes

Drug Therapy

1. Unless contraindicated (cardiovascular disease) start Terlipressin 2mg by IV bolus followed by 1–2mg every 4 to 6 hours until bleeding is controlled, for up to 48 hours.
2. Octreotide can be used if terlipressin contraindicated, but this use is unlicensed and therefore should be discussed with seniors first.
3. Start broad spectrum antibiotic cover with coamoxiclav IV 1.2g every 8 hours or if penicillin allergy ciprofloxacin IV 400mg 12 hourly. Continue antibiotics for 48 hours after cessation of bleeding (observe IV to oral switch).

Management Once Stable

1. Enter into a variceal eradication programme – discuss with gastroenterologist.
2. Variceal band ligation is treatment of choice for oesophageal varices but can be technically difficult with continued bleeding in which case sclerotherapy may be necessary.
3. Start propranolol oral 40mg twice daily if no contraindication and titrate up to 160mg once daily sustained release preparation if tolerated.
4. Give advice on alcohol intake if appropriate – abstinence alone can reduce the portal pressure.

Links

• Decompensated Liver Disease Bundle [pdf]

Content by Prof. Chris Isles