Acute Variceal Bleeding Is It Only the Success of Hemostasis That Guarantees the Positive Outcome?

Authors

  • Nikolay Tsonev Department of Gastroenterology, Clinic of Internal Diseases, 2nd MHAT, Sofia, Bulgaria
  • D. Vundeva Department of Gastroenterology, Clinic of Internal Diseases, 2nd MHAT, Sofia, Bulgaria
  • K. Toncheva Department of Gastroenterology, Clinic of Internal Diseases, 2nd MHAT, Sofia, Bulgaria
  • Dimitar Zvezdov Department of Gastroenterology, Clinic of Internal Diseases, 2nd MHAT, Sofia, Bulgaria
  • I. Petrov Department of Gastroenterology, Clinic of Internal Diseases, 2nd MHAT, Sofia, Bulgaria
  • D. Dimitrova Department of Gastroenterology, Clinic of Internal Diseases, 2nd MHAT, Sofia, Bulgaria
  • D. Petrova Department of Gastroenterology, Clinic of Internal Diseases, 2nd MHAT, Sofia, Bulgaria

DOI:

https://doi.org/10.3889/oamjms.2022.8106

Keywords:

Acute variceal bleeding, Vasoactive drugs, Endoscopic band ligation, MELD, Child-Pugh, Baveno VI recommendations

Abstract

Acute variceal bleeding remains with a high mortality rate (around 15%). Treatment is based on the combined use of vasoactive drugs, endoscopic band ligation, and antibiotic therapy. Effective resuscitation (blood transfusions, volume replacement) is essential to prevent complications. In case of failure - transjugular intrahepatic portosystemic shunt (TIPS) with appropriate indications and limitations related to the prognosis of the individual patient. Balloon tamponade or specially designed coated esophageal stents can be used as a bridge to definitive therapy in unstable patients. Early TIPS should be the first choice in patients at high risk of treatment failure (Child-Pugh B with active bleeding or Child-Pugh C < 14). This article discusses the latest advances in variceal bleeding management in line with current recommendations of the Baveno VI Consensus Conference.

Downloads

Download data is not yet available.

Metrics

Metrics Loading ...

Plum Analytics Artifact Widget Block

References

Bosch J, Albillos A, Abraldes JG, Basares R, Calleja JL, Escorsell AS, et al. Documento de consenso: Hipertensi¢n portal. Gastroenterol Hepatol. 2005;28:1-26.

Bosch J, Abraldes JG, Albillos A, Aracil C, Banares R, Berzigotti A, et al. Portal hypertension: Recommendations for evaluation and treatment: Consensus document sponsored by the Spanish association for the study of the liver (AEEH) and the biomedical research network center for liver and digestive diseases (CIBERehd). Gastroenterol Hepatol. 2012;35(6):421- 50. https://doi.org/10.1016/j.gastrohep.2012.02.009 PMid:22633191 DOI: https://doi.org/10.1016/j.gastrohep.2012.02.009

Graham DY, Smith JL. The course of patients after variceal hemorrhage. Gastroenterology. 1981;80(4):800-9. PMid:6970703 DOI: https://doi.org/10.1016/0016-5085(81)90144-X

D’Amico G, de Franchis R. Upper digestive bleeding in cirrhosis. Post-therapeutic outcome and prognostic indicators. Hepatology. 2003;38(3):599-612. https://doi.org/10.1053/jhep.2003.50385 PMid:12939586 DOI: https://doi.org/10.1053/jhep.2003.50385

Reverter E, Tandon P, Augustin S, Turon F, Casu S, Bastiampillai R, et al. A MELD-based model to determine risk of mortality among patients with acute variceal bleeding. Gastroenterology. 2014;146(2):412-9. https://doi.org/10.1053/j.gastro.2013.10.018 PMid:24148622 DOI: https://doi.org/10.1053/j.gastro.2013.10.018

Abraldes JG, Bosch J. The treatment of acute variceal bleeding. J Clin Gastroenterol. 2007;41(Suppl 3):S312-7. https://doi.org/10.1097/MCG.0b013e318150d3dd PMid:17975482 DOI: https://doi.org/10.1097/MCG.0b013e318150d3dd

Mayorga CA, Rockey DC. Clinical utility of a standardized electronic order set for the management of acute upper gastrointestinal hemorrhage in patients with cirrhosis. Clin Gastroenterol Hepatol. 2013;11(10):1342-8. https://doi.org/10.1016/j.cgh.2013.04.021 PMid:23639605 DOI: https://doi.org/10.1016/j.cgh.2013.04.021

de Franchis R. 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(4):762-8. https://doi.org/10.1016/j.jhep.2010.06.004 PMid:20638742 DOI: https://doi.org/10.1016/j.jhep.2010.06.004

Villanueva C, ColomoA, BoschA, Concepcion M, Hernandez-Gea V, Aracil C, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013;368:11-21. DOI: https://doi.org/10.1056/NEJMoa1211801

Bosch J, Thabut D, Bendtsen F, D’Amico G, Albillos A, Gonzalez AJ, et al. Recombinant factor VIIa for upper gastrointestinal bleeding in patients with cirrhosis: A randomized, double-blind trial. Gastroenterology. 2004;127(4):1123-30. https://doi.org/10.1053/j.gastro.2004.07.015 PMid:15480990 DOI: https://doi.org/10.1053/j.gastro.2004.07.015

Bosch J, Thabut D, Albillos A, Carbonell N, Spicak J, Massard J, et al. Recombinant factor VIIa for variceal bleeding in patients with advanced cirrhosis: A randomized, controlled trial. Hepatology. 2008;47(5):1604-14. https://doi.org/10.1002/hep.22216 PMid:18393319 DOI: https://doi.org/10.1002/hep.22216

Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila FI, Soares-Weiser K, Uribe M. Antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2010;2010:CD002907. https://doi.org/10.1002/14651858.CD002907.pub2 PMid:20824832 DOI: https://doi.org/10.1002/14651858.CD002907.pub2

Fernandez J, Gustot T. Management of bacterial infections in cirrhosis. J Hepatol. 2012;56(Suppl 1):S1-12. https://doi.org/10.1016/S0168-8278(12)60002-6 PMid:22300459 DOI: https://doi.org/10.1016/S0168-8278(12)60002-6

Bernard B, Grange JD, Khac EN, Amiot X, Opolon P, Poynard T. Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: A meta-analysis. Hepatology. 1999;29(6):1655-61. https://doi.org/10.1002/ hep.510290608 PMid:10347104 DOI: https://doi.org/10.1002/hep.510290608

Pauwels A, Mostefa-Kara N, Debenes B, Degoutte E, Levy VG. Systemic antibiotic prophylaxis after gastrointestinal hemorrhage in cirrhotic patients with a high risk of infection. Hepatology. 1996;24(4):802-6. https://doi.org/10.1002/hep.510240408 PMid:8855179 DOI: https://doi.org/10.1002/hep.510240408

Jalan R, Fernandez J, Wiest R, Schnabl B, Moreau R, Angeli P, et al. Bacterial infections in cirrhosis: A position statement based on the EASL special conference 2013. J Hepatol. 2014;60(6):1310-24. https://doi.org/10.1016/j.jhep.2014.01.024 PMid:24530646 DOI: https://doi.org/10.1016/j.jhep.2014.01.024

Goulis J, Armonis A, Patch D, Sabin C, Greenslade L, Burroughs AK. Bacterial infection is independently associated with failure to control bleeding in cirrhotic patients with gastrointestinal hemorrhage. Hepatology. 1998;27(5):1207-12. https://doi.org/10.1002/hep.510270504 PMid:9581672 DOI: https://doi.org/10.1002/hep.510270504

Hou MC, Lin HC, Liu TT, Kuo BI, Lee FY, Chang FY, et al. Antibiotic prophylaxis after endoscopic therapy prevents rebleeding in acute variceal hemorrhage: A randomized trial. Hepatology. 2004;39(3):746-53. https://doi.org/10.1002/hep.20126 PMid:14999693 DOI: https://doi.org/10.1002/hep.20126

Soares-Weiser K, Brezis M, Leibovici L. Antibiotics for spontaneous bacterial peritonitis in cirrhotics. Cochrane Database Syst Rev. 2001;3:CD002232. https://doi. org/10.1002/14651858.CD002232.pub2 PMid:19160207 DOI: https://doi.org/10.1002/14651858.CD002232

Garcia-Tsao G, Bosch J. Management of varices and variceal hemorrhage in cirrhosis. N Engl J Med. 2010;362:823-32. https://doi.org/10.1056/NEJMra0901512 PMid:20200386 DOI: https://doi.org/10.1056/NEJMra0901512

Carbonell N, Pauwels A, Serfaty L, Fourdan O, Levy VG, Poupon R. Improved survival after variceal bleeding in patients with cirrhosis over the past two decades. Hepatology. 2004;40(3):652-9. https://doi.org/10.1002/hep.20339 PMid:15349904 DOI: https://doi.org/10.1002/hep.20339

Tandon P, Abraldes JG, Keough A, Bastiampillai R, Jayakumar S, Carbonneau M, et al. Risk of bacterial infection in patients with cirrhosis and acute variceal hemorrhage, based on Child-Pugh class, and effects of antibiotics. Clin Gastroenterol Hepatol. 2015;13(6):1189-96.e2. https://doi.org/10.1016/j.cgh.2014.11.019 PMid:25460564 DOI: https://doi.org/10.1016/j.cgh.2014.11.019

deFranchisR,BavenoVI.Expandingconsensusinportalhypertension: report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol. 2015;63(3):743-52. https://doi.org/10.1016/j.jhep.2015.05.022 PMid:26047908 DOI: https://doi.org/10.1016/j.jhep.2015.05.022

Fernandez J, Acevedo J, Castro M, Garcia O, de Lope CR, Roca D, et al. Prevalence and risk factors of infections by multiresistant bacteria in cirrhosis: A prospective study. Hepatology. 2012;55(5):1551-61. https://doi.org/10.1002/hep.25532 PMid:22183941 DOI: https://doi.org/10.1002/hep.25532

Vilstrup H, Amodio P, Bajaj J, Cordoba J, Ferenci P, Mullen KD, et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice guideline by the American association for the study of liver diseases and the European association for the study of the liver. Hepatology. 2014;60(2):715-35. https://doi.org/10.1002/hep.27210 PMid:25042402 DOI: https://doi.org/10.1002/hep.27210

Sharma P, Agrawal A, Sharma BC, Sarin SK. Prophylaxis of hepatic encephalopathy in acute variceal bleed: A randomized controlled trial of lactulose versus no lactulose. J Gastroenterol Hepatol. 2011;26(6):996-1003. https://doi.org/10.1111/j.1440-1746.2010.06596.x PMid:21129028 DOI: https://doi.org/10.1111/j.1440-1746.2010.06596.x

Maharshi S, Sharma BC, Srivastava S, Jindal A. Randomised controlled trial of lactulose versus rifaximin for prophylaxis of hepatic encephalopathy in patients with acute variceal bleed. Gut. 2015;64(8):1341-2. https://doi.org/10.1136/gutjnl-2014-308521 PMid:25320105 DOI: https://doi.org/10.1136/gutjnl-2014-308521

Cardenas A, Gines P, Uriz J, Bessa X, Salmeron JM, Mas A, et al. Renal failure after upper gastrointestinal bleeding in cirrhosis: Incidence, clinical course, predictive factors, and short-term prognosis. Hepatology. 2001;34(4 Pt 1):671-6. https://doi.org/10.1053/jhep.2001.27830 PMid:11584362 DOI: https://doi.org/10.1053/jhep.2001.27830

Angeli P, Gines P, Wong F, Bernardi M, Boyer TD, Gerbes A, et al. Diagnosis and management of acute kidney injury in patients with cirrhosis: Revised consensus recommendations of the International Club of Ascites. Gut. 2015;64(4):531-7. https://doi.org/10.1136/gutjnl-2014-308874 PMid:25631669 DOI: https://doi.org/10.1136/gutjnl-2014-308874

Banares R, Albillos A, Rincon D, Alonso S, Gonzalez M, Ruiz-del-Arbol L, et al. Endoscopic treatment versus endoscopic plus pharmacologic treatment for acute variceal bleeding: A meta-analysis. Hepatology. 2002;35(3):609-15. https://doi.org/10.1053/jhep.2002.31354 PMid:11870374 DOI: https://doi.org/10.1053/jhep.2002.31354

Cales P, Masliah C, Bernard B, Garnier PP, Silvain C, Szostak-Talbodec N, et al. Early administration of vapreotide for variceal bleeding in patients with cirrhosis. N Engl J Med. 2001;344(1):23-8. https://doi.org/10.1056/ NEJM200101043440104 PMid:11136956 DOI: https://doi.org/10.1056/NEJM200101043440104

Lo GH, Chen WC, Wang HM, Lin CK, Chan HH, Tsai WL, et al.

Low-dose terlipressin plus banding ligation versus low-dose terlipressin alone in the prevention of very early rebleeding of oesophageal varices. Gut. 2009;58(9):1275-80. https://doi.org/10.1136/gut.2008.165910 PMid:19386609 DOI: https://doi.org/10.1136/gut.2008.165910

Wells M, Chande N, Adams P, Beaton M, Levstik M, Boyce E, et al. Meta-analysis: Vasoactive medications for the management of acute variceal bleeds. Aliment Pharmacol Ther. 2012;35(11):1267-78. https://doi.org/10.1111/j.1365-2036.2012.05088.x PMid:22486630 DOI: https://doi.org/10.1111/j.1365-2036.2012.05088.x

Sola E, Lens S, Guevara M, Martin-Llahi M, Fagundes C, Pereira G, et al. Hyponatremia in patients treated with terlipressin for severe gastrointestinal bleeding due to portal hypertension. Hepatology. 2010;l52(5):1783-90. https://doi.org/10.1002/hep.23893 PMid:20931555 DOI: https://doi.org/10.1002/hep.23893

Garcia-Tsao G, Bosch J, Groszmann RJ. Portal hypertension and variceal bleeding--unresolved issues. Summary of an American association for the study of liver diseases and European association for the study of the liver single-topic conference. Hepatology. 2008;47(5):1764-72. https://doi.org/10.1002/hep.22273 PMid:18435460 DOI: https://doi.org/10.1002/hep.22273

Bai YG, Li ZS. Meta-analysis: Erythromycin before endoscopy for acute upper gastrointestinal bleeding. Aliment Pharmacol Ther. 2011;34(2):166-71. https://doi.org/10.1111/j.1365-2036.2011.04708.x PMid:21615438 DOI: https://doi.org/10.1111/j.1365-2036.2011.04708.x

Villanueva C, Piqueras M, Aracil C, Gomez C, Lopez-Balaguer JM, Gonzalez B, et al. A randomized controlled trial comparing ligation and sclerotherapy as emergency endoscopic treatment added to somatostatin in acute variceal bleeding. J Hepatol. 2006;45(4):560-7. https://doi.org/10.1016/j.jhep.2006.05.016 PMid:16904224 DOI: https://doi.org/10.1016/j.jhep.2006.05.016

Avgerinos A, Armonis A, Stefanidis G, Mathou N, Vlachogiannakos J, Kougioumtzian A, et al. Sustained rise of portal pressure after sclerotherapy, but not band ligation, in acute variceal bleeding in cirrhosis. Hepatology. 2004;39(6):1623-30. https://doi.org/10.1002/hep.20236 PMid:15185303 DOI: https://doi.org/10.1002/hep.20236

Garcia-Tsao G, Sanyal AJ, Grace ND, Carey WD. Prevention and managementofgastroesophagealvaricesandvaricealhemorrhage in cirrhosis. Am J Gastroenterol. 2007;102(9):2086-102. https://doi.org/10.1111/j.1572-0241.2007.01481.x PMid:17727436 DOI: https://doi.org/10.1111/j.1572-0241.2007.01481.x

Bosch J, Abraldes JG, Groszmann R. Current management of portal hypertension. J Hepatol. 2003;38(Suppl 1):S54-68. https://doi.org/10.1016/s0168-8278(02)00430-0 PMid:12591186 DOI: https://doi.org/10.1016/S0168-8278(02)00430-0

Hubmann R, Bodlaj G, Czompo M, Benko L, Pichler P, Al Kathib S, et al. The use of self-expanding metal stents to treat acute esophageal variceal bleeding. Endoscopy. 2006;38(9):896-901. https://doi.org/10.1055/s-2006-944662 PMid:16981106 DOI: https://doi.org/10.1055/s-2006-944662

Wright G, Lewis H, Hogan B, Burroughs A, Patch D, O’Beirne J. A self-expanding metal stent for complicated variceal hemorrhage: Experience at a single center. Gastrointest Endosc. 2010;71(1):71-8. https://doi.org/10.1016/j.gie.2009.07.028 PMid:19879564 DOI: https://doi.org/10.1016/j.gie.2009.07.028

Marot A, Trepo E, Doerig C, Moreno C, Moradpour D, Deltenre P.

Systematic review with meta-analysis: Self-expanding metal stents in patients with cirrhosis and severe or refractory oesophageal variceal bleeding. Aliment Pharmacol Ther. 2015;42(11-12):1250-60. https://doi.org/10.1111/apt.13424 PMid:26472616 DOI: https://doi.org/10.1111/apt.13424

Escorsell A, Pavel O, Cárdenas A, Morillas R, Llop E, Villanueva C, et al. Esophageal balloon tamponade vs esophageal stent in controlling acute refractory variceal bleeding: A multicenter RCT. Hepatology. 2016;63(6):1957-67. https://doi.org/10.1002/hep.28360 PMid:26600191 DOI: https://doi.org/10.1002/hep.28360

Bosch J. Salvage transjugular intrahepatic portosystemic shunt: Is it really life-saving?. J Hepatol. 2001;35(5):658-60. https://doi.org/10.1016/s0168-8278(01)00238-0 PMid:11690713 DOI: https://doi.org/10.1016/S0168-8278(01)00238-0

Monescillo A, Martinez-Lagares F, Ruiz-del-Arbol L, Sierra A, Guevara C, Jimenez E, et al. Influence of portal hypertension and its early decompression by TIPS placement on the outcome of variceal bleeding. Hepatology. 2004;40(4):793-801. https://doi.org/10.1002/hep.20386 PMid:15382120 DOI: https://doi.org/10.1002/hep.1840400408

Garcia-Pagan JC, Caca K, Bureau C, Laleman W, Appenrodt B, Luca A, et al. Early use of TIPS in patients with cirrhosis and variceal bleeding.N Engl J Med. 2010;362(25):2370-9. https://doi.org/10.1056/NEJMoa0910102 PMid:20573925 DOI: https://doi.org/10.1056/NEJMoa0910102

Garcia-Pagan JC, Di Pascoli M, Caca K, Laleman W, Bureau C, Appenrodt B, et al. Use of early-TIPS for high-risk variceal bleeding: results of a post-RCT surveillance study. J Hepatol. 2013;58(1):45-50. https://doi.org/10.1016/j.jhep.2012.08.020 PMid:22940408 DOI: https://doi.org/10.1016/j.jhep.2012.08.020

Rudler M, Cluzel P, Corvec TL, Benosman H, Rousseau G, Poynard T, et al. Early-TIPSS placement prevents rebleeding in high-risk patients with variceal bleeding, without improving survival. Aliment Pharmacol Ther. 2014;40(9):1074-80. https://doi.org/10.1111/apt.12934 PMid:25230051 DOI: https://doi.org/10.1111/apt.12934

Kjaergard LL, Nikolova D, Gluud C. Randomized clinical trials in hepatology: Predictors of quality. Hepatology. 1999;30(5):1134-8. https://doi.org/10.1002/hep.510300510 PMid:10534332 DOI: https://doi.org/10.1002/hep.510300510

Abraldes JG, Tandon P. Soft and hard endpoints in acute variceal bleeding. Hepatology. 2015;61(3):762-5. https://doi.org/10.1002/hep.27583 PMid:253483895 DOI: https://doi.org/10.1002/hep.27583

Meeting Report from FDA Gastrointestinal Drugs Advisory Committee; 2009.

Engelmann L, Schmitt DV. Tarragona strategy--appropriate antibiotic therapy in the ICU. Med Klin Intensivmed Notfallmed. 2014;109(3):156-61. https://doi.org/10.1007/ s00063-013-0310-7 PMid:24652507 DOI: https://doi.org/10.1007/s00063-013-0310-7

Downloads

Published

2022-02-24

How to Cite

1.
Tsonev N, Vundeva D, Toncheva K, Zvezdov D, Petrov I, Dimitrova D, Petrova D. Acute Variceal Bleeding Is It Only the Success of Hemostasis That Guarantees the Positive Outcome?. Open Access Maced J Med Sci [Internet]. 2022 Feb. 24 [cited 2024 Mar. 29];10(F):90-5. Available from: https://oamjms.eu/index.php/mjms/article/view/8106

Issue

Section

Narrative Review Article

Categories