Acute Variceal Haemorrhage

Acute variceal haemorrhage is bleeding from oesophageal or gastric varices caused by portal hypertension. It is the commonest fatal complication of cirrhosis.

Epidemiology. Varices are present in about 50% of patients with cirrhosis, and bleed at a rate of 5 to 15% each year (higher with large varices, red wale signs and advanced liver disease). Six week mortality is about 15 to 20%, and over 30% in Child-Pugh class C.

Causes of portal hypertension. Cirrhosis (alcohol, viral, metabolic), portal vein thrombosis, schistosomiasis, non-cirrhotic portal hypertension, splenic vein thrombosis (isolated gastric varices) and Budd-Chiari syndrome.

Pathophysiology. Increased intrahepatic resistance and splanchnic inflow raise portal pressure above 12 mmHg (hepatic venous pressure gradient), and varices develop and rupture when wall tension exceeds strength.

Presentation is haematemesis (fresh blood or coffee ground), melaena, haematochezia, syncope, hypotension, tachycardia, with signs of chronic liver disease (jaundice, ascites, spider naevi, splenomegaly, caput medusae, encephalopathy).

Red flags.

• Haemodynamic instability or ongoing haematemesis.
• Child-Pugh class C, hepatic encephalopathy, hepatorenal failure or sepsis.
• Anticoagulation, hepatocellular carcinoma or portal vein thrombosis.

Resuscitate first. Send full blood count, coagulation, group and crossmatch, liver tests, creatinine, electrolytes, lactate and cultures. Endoscopy within 12 hours of presentation (after resuscitation) confirms the source and allows treatment. Doppler ultrasound or CT shows portal vein thrombosis and tumour.

Differential diagnosis. Peptic ulcer, portal hypertensive gastropathy, Mallory-Weiss tear, gastric antral vascular ectasia, oesophagitis, malignancy and dieulafoy lesion.

Resuscitation.

• Airway protection: intubate for ongoing haematemesis with encephalopathy or before endoscopy when aspiration risk is high.
• Two large bore IV cannulae. Volume restoration cautiously.
• Restrictive transfusion: red cells when haemoglobin is under 70 g/L, aiming for 70 to 80 g/L (over transfusion raises portal pressure and rebleeding). Higher thresholds for cardiovascular disease or massive bleeding.
• Do not correct INR with plasma (it does not reflect bleeding risk, and raises portal pressure). Platelets under 50 x 10^9/L with active bleeding are transfused, and fibrinogen under 1.0 g/L is corrected.

Vasoactive drug (start before endoscopy, continue 2 to 5 days).

• Terlipressin 2 mg IV every 4 hours for the first 48 hours, then 1 mg every 4 hours (maximum 5 days), or 2 mg IV bolus then 1 to 2 mg every 4 to 6 hours. Avoid in ischaemic heart disease, peripheral arterial disease and hypoxia, and monitor sodium.
• Octreotide 50 microgram IV bolus then 50 microgram/h infusion if terlipressin is unavailable or contraindicated.

Antibiotic prophylaxis (for up to 7 days). Ceftriaxone 1 g IV daily (adjusted to local resistance and Child-Pugh class), which reduces infection, rebleeding and death.

Erythromycin. 250 mg IV 30 to 120 minutes before endoscopy to improve visualisation (monitor QT).

Endoscopic therapy.

• Endoscopic variceal band ligation for oesophageal varices.
• Cyanoacrylate injection for gastric varices (or cyanoacrylate with balloon occluded retrograde transvenous obliteration).
• Sclerotherapy only if band ligation is not possible.

Rescue.

• Balloon tamponade (Sengstaken-Blakemore or Minnesota tube) for uncontrolled bleeding as a bridge for up to 24 hours, with airway protection, gastric port aspiration, and checks of balloon pressure.
• Self-expanding covered oesophageal stent as an alternative bridge.
• Pre-emptive transjugular intrahepatic portosystemic shunt within 72 hours (ideally within 24 hours) for Child-Pugh class C (10 to 13 points) or class B (over 7 points) with active bleeding at endoscopy. Rescue shunt for failure of control or early rebleeding.

Prevent complications.

• Lactulose 30 mL orally every 8 to 12 hours (titrated to 2 to 3 soft stools daily) to prevent encephalopathy
• Albumin for renal dysfunction
• Proton pump inhibitor for 7 to 10 days after band ligation only if ulcer is a concern
• Thiamine for alcohol use disorder

Secondary prophylaxis. Non-selective beta blocker (propranolol 20 to 40 mg orally twice daily titrated to heart rate 55 to 60 beats/min, maximum 160 mg daily without ascites and 80 mg with ascites; or carvedilol 6.25 mg daily increased to 12.5 mg daily). Combine with repeated band ligation every 2 to 4 weeks until eradication. Hold beta blockers with refractory ascites, systolic pressure under 90 mmHg, hepatorenal syndrome, or sepsis.

Monitoring. Heart rate, blood pressure, haemoglobin every 4 to 6 hours, urine output, mental state, creatinine and signs of rebleeding.

Referral and escalation. Gastroenterology or hepatology, intensive care and interventional radiology at once. Liver transplant assessment.

Special groups. In pregnancy, band ligation is preferred with octreotide, and beta blockers are used cautiously. In renal impairment, reduce terlipressin duration with monitoring and give albumin.