Among patients with cirrhosis, varices form at a rate of 5 to 15 percent per year, and one-third of patients with varices will develop variceal hemorrhage . The current treatment options for acute variceal hemorrhage include medications (vasopressin, somatostatin, and their analogs), endoscopy, transjugular intrahepatic portosystemic shunt placement, and surgery.
This topic will review the pharmacologic, endoscopic, radiologic, and surgical methods used to achieve hemostasis in patients with acute variceal hemorrhage. The general management of patients with variceal hemorrhage, primary and secondary prophylaxis against variceal hemorrhage, and a detailed discussion of endoscopic variceal ligation are discussed separately. (See "General principles of the management of variceal hemorrhage" and "Primary and pre-primary prophylaxis against variceal hemorrhage in patients with cirrhosis" and "Prevention of recurrent variceal hemorrhage in patients with cirrhosis" and "Endoscopic variceal ligation".)
The management of variceal hemorrhage is also discussed in a 2007 guideline from the American Association for the Study of Liver Diseases and a 2014 guideline from the American Society of Gastrointestinal Endoscopy . The discussion that follows is consistent with those guidelines .
NATURAL HISTORY AND PROGNOSIS WITH TREATMENT
Older studies suggest that variceal hemorrhage will stop spontaneously in approximately half of patients, though rebleeding is common . Bleeding is less likely to stop spontaneously in patients with Child class C cirrhosis, active variceal bleeding at the time of endoscopy, or if the hepatic venous pressure gradient (HVPG) is greater than 20 mmHg . Approximately 70 percent of untreated patients die within the first year after their initial variceal hemorrhage. The causes of death include recurrent variceal hemorrhage, liver failure, hepatic encephalopathy, progressive ascites, and infections. Treatment with either endoscopic variceal ligation or endoscopic sclerotherapy is associated with decreases in both rebleeding rates and mortality.
If the bleeding stops spontaneously, it is estimated that rebleeding will occur in approximately one-third of patients within six weeks (early rebleeding) and in 70 percent of patients over the long-term [5-7]. Approximately half of the patients with early rebleeding will rebleed within three to four days of the index bleed.