Morning Report 11/2 – Esophageal Variceal (EV) Bleeding

Teaching Pearls:

  • Esophageal varices are seen in roughly 50% of patients with cirrhosis.
  • About 33% of patients with cirrhosis and esophageal varices will have at least one clinical presentation of esophageal variceal (EV) bleeding.
  • Mortality of 15-20% associated with each episode of esophageal bleeding event.
  • EV bleeding comprises of 33% of all cirrhosis-related deaths.
  • Risk of EV bleeding correlates with size of varices and other characteristics such as nipple sign and red wales sign.
  • Pre-primary prophylaxis – Management of cirrhotic patients without esophageal varices
    • Management focuses on treating the underlying cause of cirrhosis.
    • Screening occurs ~2-3 years.
  • Primary Prophylaxis – Management of cirrhotic patients with EV but no clinical history of GI bleed.
    • Medical management with beta blockers
      • Performed in those with medium-large varices, or small varices with red wales/nipple sign.
    • Esophageal band ligation
      • Performed in those with large varices
    • Continued Monitoring
      • Those with small EV without red wales/nipple sign.
  • Immediate interventions to consider in patients with suspected EV bleeding:
    • At least 2 large bore PIVs (16 or 18G) or central line
    • Fluid resuscitation
    • Type and screen blood
    • Monitor hemodynamics
    • Start protonix (bolus and gtt) and octreotide (bolus and gtt)
    • Start ceftriaxone for SBP prophylaxis
  • Pantoprazole
    • PPI will increase the pH of the gastric lumen to 5-6 from 1-2.
    • pH changes help with improving clot formation
  • Octreotide
    • Works by inhibiting endogenous substances – leads to splanchnic vasoconstriction, decreasing portal flow, leading to decreased portal pressures.
  • SBP Prophylaxis Conditions
    • History of SBP
    • Cirrhosis with GI bleed
    • Ascitic TP <1
  • Management of gastric varices differ from esophageal varices.
    • Cyanoacrylate injection and/or TIPS

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