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.
- Medical management with beta blockers
- 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