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Treatment of active variceal hemorrhage

INTRODUCTION

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".)

PROPHYLACTIC ANTIBIOTICS

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 [1]. 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 [2].

                                

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Literature review current through: Apr 2013. | This topic last updated: Nov 20, 2012.
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References
Top
  1. Garcia-Tsao G, Sanyal AJ, Grace ND, et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology 2007; 46:922.
  2. Fernández J, Ruiz del Arbol L, Gómez C, et al. Norfloxacin vs ceftriaxone in the prophylaxis of infections in patients with advanced cirrhosis and hemorrhage. Gastroenterology 2006; 131:1049.
  3. Blei AT, Groszmann RJ. Vasopressin and vasoconstrictors. In: The Physiology of the Intestinal Microcirculation, Shepherd AP, Granger DN (Eds), Raven Press, New York 1984. p.377.
  4. Ioannou G, Doust J, Rockey DC. Terlipressin for acute esophageal variceal hemorrhage. Cochrane Database Syst Rev 2003; :CD002147.
  5. Groszmann RJ, Kravetz D, Bosch J, et al. Nitroglycerin improves the hemodynamic response to vasopressin in portal hypertension. Hepatology 1982; 2:757.
  6. Gimson AE, Westaby D, Hegarty J, et al. A randomized trial of vasopressin and vasopressin plus nitroglycerin in the control of acute variceal hemorrhage. Hepatology 1986; 6:410.
  7. Tsai YT, Lay CS, Lai KH, et al. Controlled trial of vasopressin plus nitroglycerin vs. vasopressin alone in the treatment of bleeding esophageal varices. Hepatology 1986; 6:406.
  8. Bosch J, Groszmann RJ, García-Pagán JC, et al. Association of transdermal nitroglycerin to vasopressin infusion in the treatment of variceal hemorrhage: a placebo-controlled clinical trial. Hepatology 1989; 10:962.
  9. Baik SK, Jeong PH, Ji SW, et al. Acute hemodynamic effects of octreotide and terlipressin in patients with cirrhosis: a randomized comparison. Am J Gastroenterol 2005; 100:631.
  10. Abid S, Jafri W, Hamid S, et al. Terlipressin vs. octreotide in bleeding esophageal varices as an adjuvant therapy with endoscopic band ligation: a randomized double-blind placebo-controlled trial. Am J Gastroenterol 2009; 104:617.
  11. Bloom SR, Polak JM. Somatostatin. Br Med J (Clin Res Ed) 1987; 295:288.
  12. Escorsell A, Bandi JC, Andreu V, et al. Desensitization to the effects of intravenous octreotide in cirrhotic patients with portal hypertension. Gastroenterology 2001; 120:161.
  13. Albillos A, Colombato LA, Lee FY, Groszmann RJ. Octreotide ameliorates vasodilatation and Na+ retention in portal hypertensive rats. Gastroenterology 1993; 104:575.
  14. McCormick PA, Biagini MR, Dick R, et al. Octreotide inhibits the meal-induced increases in the portal venous pressure of cirrhotic patients with portal hypertension: a double-blind, placebo-controlled study. Hepatology 1992; 16:1180.
  15. Spahr L, Giostra E, Frossard JL, et al. A 3-month course of long-acting repeatable octreotide (sandostatin LAR) improves portal hypertension in patients with cirrhosis: a randomized controlled study. Am J Gastroenterol 2007; 102:1397.
  16. Chen L, Groszmann RJ. Blood in the gastric lumen increases splanchnic blood flow and portal pressure in portal-hypertensive rats. Gastroenterology 1996; 111:1103.
  17. Ludwig D, Schädel S, Brüning A, et al. 48-hour hemodynamic effects of octreotide on postprandial splanchnic hyperemia in patients with liver cirrhosis and portal hypertension: double-blind, placebo-controlled study. Dig Dis Sci 2000; 45:1019.
  18. Valenzuela JE, Schubert T, Fogel MR, et al. A multicenter, randomized, double-blind trial of somatostatin in the management of acute hemorrhage from esophageal varices. Hepatology 1989; 10:958.
  19. Imperiale TF, Teran JC, McCullough AJ. A meta-analysis of somatostatin versus vasopressin in the management of acute esophageal variceal hemorrhage. Gastroenterology 1995; 109:1289.
  20. D'Amico G, Pietrosi G, Tarantino I, Pagliaro L. Emergency sclerotherapy versus vasoactive drugs for variceal bleeding in cirrhosis: a Cochrane meta-analysis. Gastroenterology 2003; 124:1277.
  21. Planas R, Quer JC, Boix J, et al. A prospective randomized trial comparing somatostatin and sclerotherapy in the treatment of acute variceal bleeding. Hepatology 1994; 20:370.
  22. Sung JJ, Chung SC, Lai CW, et al. Octreotide infusion or emergency sclerotherapy for variceal haemorrhage. Lancet 1993; 342:637.
  23. Bildozola M, Kravetz D, Argonz J, et al. Efficacy of octreotide and sclerotherapy in the treatment of acute variceal bleeding in cirrhotic patients. A prospective, multicentric, and randomized clinical trial. Scand J Gastroenterol 2000; 35:419.
  24. Besson I, Ingrand P, Person B, et al. Sclerotherapy with or without octreotide for acute variceal bleeding. N Engl J Med 1995; 333:555.
  25. Avgerinos A, Nevens F, Raptis S, Fevery J. Early administration of somatostatin and efficacy of sclerotherapy in acute oesophageal variceal bleeds: the European Acute Bleeding Oesophageal Variceal Episodes (ABOVE) randomised trial. Lancet 1997; 350:1495.
  26. D'Amico G, Politi F, Morabito A, et al. Octreotide compared with placebo in a treatment strategy for early rebleeding in cirrhosis. A double blind, randomized pragmatic trial. Hepatology 1998; 28:1206.
  27. Primignani M, Andreoni B, Carpinelli L, et al. Sclerotherapy plus octreotide versus sclerotherapy alone in the prevention of early rebleeding from esophageal varices: a randomized, double-blind, placebo-controlled, multicenter trial. New Italian Endoscopic Club. Hepatology 1995; 21:1322.
  28. Villanueva C, Ortiz J, Sàbat M, et al. Somatostatin alone or combined with emergency sclerotherapy in the treatment of acute esophageal variceal bleeding: a prospective randomized trial. Hepatology 1999; 30:384.
  29. Bañares R, Albillos A, Rincón D, et al. Endoscopic treatment versus endoscopic plus pharmacologic treatment for acute variceal bleeding: a meta-analysis. Hepatology 2002; 35:609.
  30. D'amico G, Criscuoli V, Fili D, et al. Meta-analysis of trials for variceal bleeding. Hepatology 2002; 36:1023.
  31. Sung JJ, Chung SC, Yung MY, et al. Prospective randomised study of effect of octreotide on rebleeding from oesophageal varices after endoscopic ligation. Lancet 1995; 346:1666.
  32. Calès P, Masliah C, Bernard B, et al. Early administration of vapreotide for variceal bleeding in patients with cirrhosis. N Engl J Med 2001; 344:23.
  33. Ferayorni, L, Polio, J, Groszmann, RJ. Drug therapy for portal hypertension: A 5 year review. In: Portal Hypertension: Proceedings of the Second Baveno International Consensus Workshop on Definitions, Methodology and Therapeutic Strategies, DeFranchis, R (Eds), Blackwell Science, Oxford 1996. p.68.
  34. Moitinho E, Planas R, Bañares R, et al. Multicenter randomized controlled trial comparing different schedules of somatostatin in the treatment of acute variceal bleeding. J Hepatol 2001; 35:712.
  35. Gotzsche PC. Somatostatin or octreotide for acute bleeding oesophageal varices. Cochrane Database Syst Rev 2000; :CD000193.
  36. Grace ND. Diagnosis and treatment of gastrointestinal bleeding secondary to portal hypertension. American College of Gastroenterology Practice Parameters Committee. Am J Gastroenterol 1997; 92:1081.
  37. Escorsell A, Ruiz del Arbol L, Planas R, et al. Multicenter randomized controlled trial of terlipressin versus sclerotherapy in the treatment of acute variceal bleeding: the TEST study. Hepatology 2000; 32:471.
  38. Stiegmann GV, Goff JS, Michaletz-Onody PA, et al. Endoscopic sclerotherapy as compared with endoscopic ligation for bleeding esophageal varices. N Engl J Med 1992; 326:1527.
  39. Lo GH, Lai KH, Cheng JS, et al. Emergency banding ligation versus sclerotherapy for the control of active bleeding from esophageal varices. Hepatology 1997; 25:1101.
  40. Laine L, Cook D. Endoscopic ligation compared with sclerotherapy for treatment of esophageal variceal bleeding. A meta-analysis. Ann Intern Med 1995; 123:280.
  41. Saeed ZA, Michaletz PA, Winchester CB, et al. Endoscopic variceal ligation in patients who have failed endoscopic sclerotherapy. Gastrointest Endosc 1990; 36:572.
  42. Schuman BM, Beckman JW, Tedesco FJ, et al. Complications of endoscopic injection sclerotherapy: a review. Am J Gastroenterol 1987; 82:823.
  43. Sanowski RA, Waring JP. Endoscopic techniques and complications in variceal sclerotherapy. J Clin Gastroenterol 1987; 9:504.
  44. de Franchis R, Baveno V Faculty. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol 2010; 53:762.
  45. Grace ND, Groszmann RJ, Garcia-Tsao G, et al. Portal hypertension and variceal bleeding: an AASLD single topic symposium. Hepatology 1998; 28:868.
  46. Wright G, Lewis H, Hogan B, et al. A self-expanding metal stent for complicated variceal hemorrhage: experience at a single center. Gastrointest Endosc 2010; 71:71.
  47. D'Amico G, Pagliaro L, Bosch J. The treatment of portal hypertension: a meta-analytic review. Hepatology 1995; 22:332.
  48. Chojkier M, Conn HO. Esophageal tamponade in the treatment of bleeding varices. A decadel progress report. Dig Dis Sci 1980; 25:267.
  49. Hunt PS, Korman MG, Hansky J, Parkin WG. An 8-year prospective experience with balloon tamponade in emergency control of bleeding esophageal varices. Dig Dis Sci 1982; 27:413.
  50. Fort E, Sautereau D, Silvain C, et al. A randomized trial of terlipressin plus nitroglycerin vs. balloon tamponade in the control of acute variceal hemorrhage. Hepatology 1990; 11:678.
  51. Paquet KJ, Feussner H. Endoscopic sclerosis and esophageal balloon tamponade in acute hemorrhage from esophagogastric varices: a prospective controlled randomized trial. Hepatology 1985; 5:580.
  52. Pitcher JL. Safety and effectiveness of the modified Sengstaken-Blakemore tube: a prospective study. Gastroenterology 1971; 61:291.
  53. Minocha A, Richards RJ. Sengstaken-Blakemore tube for control of massive bleeding from gastric varices in hiatal hernia. J Clin Gastroenterol 1992; 14:36.
  54. Bajaj JS, Ananthakrishnan A, Saeian K. Survey of attitudes of AASLD members toward balloon tamponade. Hepatology 2005; 41:1435.
  55. Orloff MJ, Isenberg JI, Wheeler HO, et al. Randomized trial of emergency endoscopic sclerotherapy versus emergency portacaval shunt for acutely bleeding esophageal varices in cirrhosis. J Am Coll Surg 2009; 209:25.
  56. Cello JP, Grendell JH, Crass RA, et al. Endoscopic sclerotherapy versus portacaval shunt in patients with severe cirrhosis and variceal hemorrhage. N Engl J Med 1984; 311:1589.
  57. Burroughs AK, Hamilton G, Phillips A, et al. A comparison of sclerotherapy with staple transection of the esophagus for the emergency control of bleeding from esophageal varices. N Engl J Med 1989; 321:857.
  58. Selzner M, Tuttle-Newhall JE, Dahm F, et al. Current indication of a modified Sugiura procedure in the management of variceal bleeding. J Am Coll Surg 2001; 193:166.
  59. Monescillo A, Martínez-Lagares F, Ruiz-del-Arbol L, et al. Influence of portal hypertension and its early decompression by TIPS placement on the outcome of variceal bleeding. Hepatology 2004; 40:793.
  60. LaBerge JM, Ring EJ, Gordon RL, et al. Creation of transjugular intrahepatic portosystemic shunts with the wallstent endoprosthesis: results in 100 patients. Radiology 1993; 187:413.
  61. Rössle M, Haag K, Ochs A, et al. The transjugular intrahepatic portosystemic stent-shunt procedure for variceal bleeding. N Engl J Med 1994; 330:165.
  62. Sanyal AJ, Freedman AM, Luketic VA, et al. Transjugular intrahepatic portosystemic shunts for patients with active variceal hemorrhage unresponsive to sclerotherapy. Gastroenterology 1996; 111:138.
  63. Rosemurgy AS, Goode SE, Zwiebel BR, et al. A prospective trial of transjugular intrahepatic portasystemic stent shunts versus small-diameter prosthetic H-graft portacaval shunts in the treatment of bleeding varices. Ann Surg 1996; 224:378.
  64. Jalan R, John TG, Redhead DN, et al. A comparative study of emergency transjugular intrahepatic portosystemic stent-shunt and esophageal transection in the management of uncontrolled variceal hemorrhage. Am J Gastroenterol 1995; 90:1932.
  65. Sarin SK. Long-term follow-up of gastric variceal sclerotherapy: an eleven-year experience. Gastrointest Endosc 1997; 46:8.
  66. Trudeau W, Prindiville T. Endoscopic injection sclerosis in bleeding gastric varices. Gastrointest Endosc 1986; 32:264.
  67. Soehendra N, Nam VC, Grimm H, Kempeneers I. Endoscopic obliteration of large esophagogastric varices with bucrylate. Endoscopy 1986; 18:25.
  68. Kind R, Guglielmi A, Rodella L, et al. Bucrylate treatment of bleeding gastric varices: 12 years' experience. Endoscopy 2000; 32:512.
  69. Huang YH, Yeh HZ, Chen GH, et al. Endoscopic treatment of bleeding gastric varices by N-butyl-2-cyanoacrylate (Histoacryl) injection: long-term efficacy and safety. Gastrointest Endosc 2000; 52:160.
  70. Lee YT, Chan FK, Ng EK, et al. EUS-guided injection of cyanoacrylate for bleeding gastric varices. Gastrointest Endosc 2000; 52:168.
  71. Lo GH, Lai KH, Cheng JS, et al. A prospective, randomized trial of butyl cyanoacrylate injection versus band ligation in the management of bleeding gastric varices. Hepatology 2001; 33:1060.
  72. Sarin SK, Jain AK, Jain M, Gupta R. A randomized controlled trial of cyanoacrylate versus alcohol injection in patients with isolated fundic varices. Am J Gastroenterol 2002; 97:1010.
  73. Datta D, Vlavianos P, Alisa A, Westaby D. Use of fibrin glue (beriplast) in the management of bleeding gastric varices. Endoscopy 2003; 35:675.
  74. Seewald S, Ang TL, Imazu H, et al. A standardized injection technique and regimen ensures success and safety of N-butyl-2-cyanoacrylate injection for the treatment of gastric fundal varices (with videos). Gastrointest Endosc 2008; 68:447.
  75. Holster IL, Poley JW, Kuipers EJ, Tjwa ET. Controlling gastric variceal bleeding with endoscopically applied hemostatic powder (Hemospray™). J Hepatol 2012; 57:1397.
  76. Jutabha R, Jensen DM. Management of upper gastrointestinal bleeding in the patient with chronic liver disease. Med Clin North Am 1996; 80:1035.
  77. Chau TN, Patch D, Chan YW, et al. "Salvage" transjugular intrahepatic portosystemic shunts: gastric fundal compared with esophageal variceal bleeding. Gastroenterology 1998; 114:981.
  78. Mishra SR, Chander Sharma B, Kumar A, Sarin SK. Endoscopic cyanoacrylate injection versus beta-blocker for secondary prophylaxis of gastric variceal bleed: a randomised controlled trial. Gut 2010; 59:729.
  79. Hung HH, Chang CJ, Hou MC, et al. Efficacy of non-selective β-blockers as adjunct to endoscopic prophylactic treatment for gastric variceal bleeding: a randomized controlled trial. J Hepatol 2012; 56:1025.
  80. Cheng LF, Wang ZQ, Li CZ, et al. Low incidence of complications from endoscopic gastric variceal obturation with butyl cyanoacrylate. Clin Gastroenterol Hepatol 2010; 8:760.
  81. Binmoeller KF, Weilert F, Shah JN, Kim J. EUS-guided transesophageal treatment of gastric fundal varices with combined coiling and cyanoacrylate glue injection (with videos). Gastrointest Endosc 2011; 74:1019.
  82. Shiha G, El-Sayed SS. Gastric variceal ligation: a new technique. Gastrointest Endosc 1999; 49:437.
  83. Ramesh J, Limdi JK, Sharma V, Makin AJ. The use of thrombin injections in the management of bleeding gastric varices: a single-center experience. Gastrointest Endosc 2008; 68:877.
  84. Przemioslo RT, McNair A, Williams R. Thrombin is effective in arresting bleeding from gastric variceal hemorrhage. Dig Dis Sci 1999; 44:778.
  85. Yang WL, Tripathi D, Therapondos G, et al. Endoscopic use of human thrombin in bleeding gastric varices. Am J Gastroenterol 2002; 97:1381.
  86. Lee MS, Cho JY, Cheon YK, et al. Use of detachable snares and elastic bands for endoscopic control of bleeding from large gastric varices. Gastrointest Endosc 2002; 56:83.
  87. Akahoshi T, Hashizume M, Tomikawa M, et al. Long-term results of balloon-occluded retrograde transvenous obliteration for gastric variceal bleeding and risky gastric varices: a 10-year experience. J Gastroenterol Hepatol 2008; 23:1702.
  88. Cho SK, Shin SW, Lee IH, et al. Balloon-occluded retrograde transvenous obliteration of gastric varices: outcomes and complications in 49 patients. AJR Am J Roentgenol 2007; 189:W365.
  89. Yoshimatsu R, Yamagami T, Tanaka O, et al. Development of thrombus in a systemic vein after balloon-occluded retrograde transvenous obliteration of gastric varices. Korean J Radiol 2012; 13:324.
  90. Bernstein D, Yrizarry J, Reddy KR, et al. Transjugular intrahepatic portosystemic shunt in the treatment of intermittently bleeding stomal varices. Am J Gastroenterol 1996; 91:2237.
  91. Allgaier HP, Ochs A, Haag K, et al. [Recurrent bleeding from colonic varices in portal hypertension. The successful prevention of recurrence by the implantation of a transjugular intrahepatic stent-shunt (TIPS)]. Dtsch Med Wochenschr 1995; 120:1773.
  92. Sort P, Elizalde I, Llach I, et al. Duodenal variceal bleeding treated with a transjugular intrahepatic portosystemic shunt. Endoscopy 1995; 27:626.
  93. Boyer TD, Haskal ZJ, American Association for the Study of Liver Diseases. The Role of Transjugular Intrahepatic Portosystemic Shunt (TIPS) in the Management of Portal Hypertension: update 2009. Hepatology 2010; 51:306.
  94. Hashimoto N, Akahoshi T, Yoshida D, et al. The efficacy of balloon-occluded retrograde transvenous obliteration on small intestinal variceal bleeding. Surgery 2010; 148:145.