Sections View Full Chapter Figures Tables Videos Full Chapter Figures Tables Videos Supplementary Content + Print Section ++ For further information, see CMDT Part 15-19: Benign Esophageal Lesions + Key Features Print Section ++ ++ Essentials of Diagnosis ++ Develop secondary to portal hypertension Found in 50% of patients with cirrhosis Upper gastrointestinal bleeding develops in one-third Diagnosis established by upper endoscopy ++ General Considerations ++ Esophageal varices are dilated submucosal veins that develop in patients with underlying portal hypertension and may result in serious upper gastrointestinal bleeding Bleeding most commonly occurs in the distal 5 cm of the esophagus Approximately 50% of patients with cirrhosis have esophageal varices Bleeding from varices occurs in 30% of patients with esophageal varices In the absence of any treatment, variceal bleeding spontaneously stops in about 50% of patients Patients surviving this bleeding episode have a 60% chance of recurrent variceal bleeding, usually within the first 6 weeks Factors that may portend an increased risk of bleeding include Size of the varices Presence at endoscopy of red wale markings on the varix Severity of liver disease (as assessed by Child-Pugh score) Active alcohol abuse—patients with cirrhosis who continue to drink have an extremely high risk of bleeding + Clinical Findings Print Section ++ ++ Symptoms and Signs ++ Acute gastrointestinal hemorrhage, usually severe, resulting in hypovolemia, postural vital signs, or shock ++ Differential Diagnosis ++ Alcoholic gastritis Mallory-Weiss syndrome Portal hypertensive gastropathy Peptic ulcer disease Gastric or duodenal varices (rare) Vascular ectasias (angiodysplasias), eg, idiopathic arteriovenous malformation, CREST syndrome, hereditary hemorrhagic telangiectasia + Diagnosis Print Section ++ ++ Laboratory Tests ++ Complete blood count, platelet count, prothrombin time, INR Serum liver enzymes Creatinine, blood urea nitrogen If bleeding, blood type and cross-match ++ Diagnostic Procedures ++ After the patient's hemodynamic status has been stabilized, emergent upper endoscopy is diagnostic + Treatment Print Section ++ ++ Medications ++ Antibiotic prophylaxis reduces the risk of serious infection in hospitalized patients with cirrhosis and upper GI bleeding Prophylactic administration of oral or intravenous antibiotics reduces the risk of serious infection to 10–20% as well as in-hospital mortality, especially in patients with Child-Pugh class C cirrhosis Norfloxacin, 400 mg orally twice daily for 5–7 days Ceftriaxone 1 g/d intravenously for 5–7 days Vasoactive agents Somatostatin, (250 mcg/h; not available in the United States) or octreotide, (50 mcg intravenous bolus followed by 50 mcg/h intravenously) infusion reduces splanchnic and hepatic blood flow and portal pressures Terlipressin (1–2 mg intravenous every 4 hours; not available in the United States) causes significant reduction in portal and variceal pressures and, where available, may be preferred over octreotide Combined vasoactive agents and endoscopic therapy (band ligation or sclerotherapy) Superior to either modality alone in controlling acute bleeding and early rebleeding May improve survival Vitamin K, 10 mg subcutaneously Lactulose 30 mL orally every 2–3 hours until evacuation occurs, then reduced to 15–45 mL/h every 8–12 hours as needed to promote 2–3 bowel movements daily for hepatic encephalopathy After bleeding stops, administer β-blocker to reduce portal pressure Propranolol, 20–60 mg twice daily orally; long-acting propranolol, 60–80 mg once daily orally; or nadolol, 40 mg once daily orally Gradually increase dosage until heart rate falls by 25% or reaches 55–60 beats/min ++ Surgery ++ Transvenous intrahepatic portosystemic shunt (TIPS) has resulted in a significant reduction in recurrent bleeding compared with endoscopic sclerotherapy or band ligation—either alone or in combination with β-blocker therapy TIPS reserved for patients who Have recurrent (≥ 2 episodes) bleeding from gastric varices or portal hypertensive gastropathy (for which endoscopic therapies cannot be used) Have not responded to endoscopic or pharmacologic therapies Are noncompliant with other therapies Live in remote locations (without access to emergency care) Shunt surgery is seldom performed due to the advent and widespread adoption of TIPS Liver transplantation ++ Therapeutic Procedures ++ Initial management involves rapid assessment and acute resuscitation with fluids or blood products Transfusion of fresh frozen plasma or platelets to patients with INRs > 1.8–2.0 or platelet counts < 50,000/mcL in the presence of active bleeding Mechanical tamponade with nasogastric tubes containing large gastric and esophageal balloons (Minnesota or Sengstaken-Blakemore tubes) Provides initial control of active variceal hemorrhage in 60–90% of patients However, rebleeding occurs in 50% Acute endoscopic treatment of the varices generally is performed with banding; in current clinical practice, sclerotherapy is seldom used Banding arrests active bleeding in 80–90% of patients and reduces the chance of in-hospital recurrent bleeding to about 20% Repeat banding at intervals of 2–4 weeks until the varices are obliterated or reduced to a small size Long-term treatment with banding achieves lower rates of rebleeding, complications, and death than sclerotherapy For patients with platelet counts < 50,000/mcL, Administering avatrombopag before the procedure should be considered At a dose of 40–60 mg/day for 5 consecutive days beginning 10–13 days prior to endoscopy, phase III clinical trials results showed that 68% of patients with baseline platelet counts < 40,000/mcL and 88% with baseline counts 40–50,000/mcL achieved platelet counts > 50,000/mcL and avoided periprocedural platelet transfusions Sclerotherapy is occasionally used for actively bleeding patients (in whom visualization for banding may be difficult) + Outcome Print Section ++ ++ Follow-Up ++ Stenosis and thrombosis of the TIPS occur in the majority over time with a consequent risk of rebleeding; monitor shunt periodically with Doppler ultrasonography or hepatic venography ++ Complications ++ Complications of TIPS include Hepatic encephalopathy in 35% Hepatic failure Complications of sclerotherapy occur in 20–30% and include Chest pain Fever Bacteremia Esophageal ulceration, stricture, and perforation Complications of mechanical tamponade include Esophageal and oral ulcerations Perforation Aspiration Airway obstruction ++ Prognosis ++ With current therapies, the in-hospital mortality rate associated with bleeding esophageal varices is 12% Mortality rate within 2 weeks after an acute bleeding episode is 20% Mortality rate at 2 years is 60% due to recurrent bleeding or progression of chronic liver disease ++ Prevention ++ Nonselective β-adrenergic blockers (propranolol, nadolol) reduce the risk of rebleeding from esophageal varices to about 40% Likewise, long-term treatment with band ligation reduces the incidence of rebleeding to about 30% ++ When to Refer ++ All patients with upper GI bleeding and suspected varices should be evaluated by a physician skilled in therapeutic endoscopy Patients with cirrhosis for endoscopic evaluation for varices Patients being considered for TIPS procedures or liver transplantation ++ When to Admit ++ All patients with acute upper GI bleeding and suspected cirrhosis should be admitted to an ICU + References Print Section ++ + +Albillos A et al. Baveno Cooperation. Stratifying risk in the prevention of recurrent variceal hemorrhage: results of an individual patient meta-analysis. Hepatology. 2017 Oct;66(4):1219–31. [PubMed: 28543862] + +Baiges A et al. Pharmacologic prevention of variceal bleeding and rebleeding. Hepatol Int. 2018 Feb;12(Suppl 1):68–80. [PubMed: 29210030] + +Brunner F et al. Prevention and treatment of variceal haemorrhage in 2017. Liver Int. 2017 Jan;37(Suppl 1):104–15. [PubMed: 28052623] + +Ibrahim M et al. New developments in managing variceal bleeding. Gastroenterology. 2018 May;154(7):1964–9. [PubMed: 29481777] + +Moon AM et al. Use of antibiotics among patients with cirrhosis and upper gastrointestinal bleeding is associated with reduced mortality. Clin Gastroenterol Hepatol. 2016 Nov;14(11):1629–37. [PubMed: 27311621] + +Saab S et al. Management of thrombocytopenia in patients with chronic liver disease. Dig Dis Sci. 2019 Apr 22. [Epub ahead of print] [PubMed: 31011942] + +Terrault N et al. Avatrombopag before procedures reduces need for platelet transfusion in patients with chronic liver disease and thrombocytopenia. Gastroenterology. 2018 Sep;155(3):705–18. [PubMed: 29778606]