The ideal treatment of active variceal hemorrhage would be universally effective, completely safe, easy to administer, and inexpensive. The current treatment options include medications (vasopressin and somatostatin and their analogs), endoscopy, surgery, and transjugular intrahepatic portosystemic shunting. None of the existing modalities come close to being ideal and the choice of one modality over another depends upon their relative efficacy, ease of administration, safety, and cost considerations.
This topic will review the treatment modalities for active variceal hemorrhage. The general principles involved in the management of patients with variceal hemorrhage as well as a more detailed discussion of endoscopic variceal ligation are discussed separately. (See "General principles of the management of variceal hemorrhage" and "Endoscopic variceal ligation".)
GENERAL PRINCIPLES OF SUPPORT
The general principles of support of patients presenting with variceal bleeding such as transfusion, prevention of aspiration, and use of recombinant factors are presented separately. (See "General principles of the management of variceal hemorrhage".)
Multiple trials evaluating the effectiveness of prophylactic antibiotics in cirrhotic patients hospitalized for bleeding suggest an overall reduction in infectious complications and possibly decreased mortality. Antibiotics may also reduce the risk of recurrent bleeding in hospitalized patients who bled from esophageal varices. Thus, patients with cirrhosis who present with upper GI bleeding (from varices or other causes) should be given prophylactic antibiotics, preferably before endoscopy (although effectiveness has also been demonstrated when given after endoscopy). (See "General principles of the management of variceal hemorrhage" and 'AASLD guidelines' below.)
The AASLD guidelines recommend short-term (maximum seven days) antibiotic prophylaxis in any patient with cirrhosis and GI hemorrhage . Oral norfloxacin (400 mg twice daily) or intravenous ciprofloxacin (in patients in whom oral administration is not possible) is the recommended antibiotic. A randomized trial found superiority of ceftriaxone over norfloxacin in preventing bacterial infections .