Management Variceal haemorrhage

Airway

Early RSI by senior anaesthetist if

  • Severe uncontrolled haemorrhage
  • Severe encephalopathy
  • Inability to maintain oxygen saturation
  • Aspiration pneumonitis

Breathing

  • High flow oxygen via reservoir bag
  • Saturation monitoring
  • Check for aspiration or infective pneumonia
  • Blood gases (beware bleeding if arterial sample)
  • CXR

Circulation

  • Intravenous access- minimum 2 x 16 gauge cannulae.
  • X-match 6 units of blood, ( FBC, U&Es, clotting, LFTs)
  • IV fluid – crystalloid or colloid then blood
  • Aim for systolic BP  80 - 90 mmHg [permissive hypotension (* Ref) ]
  • Correct PTT
  • Central venous access ( compressible site )
  • Pressure monitoring ( ideally correct clotting first)
  • Catheterise (monitor hourly output)
  • Vitamin K 5 mg slow IV and prothrombin complex concentrate 50ug/kg or FFP 15ml/kg, +/- platelets

Stopping the bleeding

Therapeutic

  • 2mg Terlipressin [Cochrane] in all unstable patients (beware myocardial ischaemia - treat with GTN patch or infusion)

Endoscopy   (Cochrane)

At CUH, patients presenting hypotensive (Sys BP < 100mmHg) or Hb < 10 g/dl should be admitted under the surgical team on call. (Letter)

  • Call on call endoscopist via switchboard
  • Scoping will confirm Dx and allow band ligation 
  • May be performed as soon as patient stable
  • May be performed as a life saving procedure in any critical area

Balloon tamponade (Senstaken tube)

  • Must always be preceded by airway protection (ETT) and sedation
  • Is reserved for severe uncontrolled haemorrhage and should be discussed with the on-call endoscopist prior to use
  • Inflate the gastric balloon and apply continuous gentle traction. It is rarely necessary to inflate oesophageal balloon.

Further management

  • Prophylactic antibiotics [Cochrane] (ciprofloxacin or Ceftazidine) in confirmed variceal bleeds (** Ref )

Differential diagnosis

  • Peptic ulceration, Portal hypertensive gastropathy
  • Gastric or duodenal varices
  • Aorto-enteric fistula

Reference

* Ref     Gav P, Chapman R. Modern Management of Oesophageal varices. Postgrad Med J.2001;77:75-81

** Ref    Bernard B, Grange JD. Antibiotic prophylaxis for the prevention of bacterial infections in chirotic patients with gastrointestinal bleeding: a meta-analysis. Hepatology 1999;29:1655-61

Links

EBOC level 1(a or b) evidence for management variceal haemorrhage     Athens password needed