by hidayat at drhidayat.com

1. Clinical Practice Guideline, May 2004

2.  10-30% of upper gastrointestinal
haemorrhage
 is a major cause of death in patients with
cirrhosis.
 The aetiology of cirrhosis in Malaysia is
mainly due to hepatitis B or alcohol
 In alcoholic liver disease, continued
abstinence from alcohol may result in a
decreasing in size or even disappearance of
varices.

3. • Severe consequence of portal hypertension secondary
to cirrhosis
• Core symptoms co-exist with other emotional,
behavioral & learning disorders
Definition
Co-
morbidities
• varies from 24-81% in oesophageal varices in patients
with cirrhosis
• 60% of decompensated cirrhosis and 30% of
compensated cirrhosis patients
Prevalence
Classification

4. Japanese US VATrial Paquet
Absent Absent Absent Absent
Grade 1: small, straight varices not
disappearing with insufflation
Small < 5 mm I
Grade 2: medium varices occupying
less than one third of the lumen
Medium 5-9 mm II
Grade 3: large varices occupying
more than one third of the lumen
Large >9 mm III
Giant IV

5. Increase
resistance to
portal flow
Increase portal
pressure
Varices
Variceal
growth
Decrease
arteriolar
resistance
Increase portal
blood inflow
Cirrhosis

6.  Severity of the liver dysfunction
 Size of the varices (large greater than
small)
 Presence of endoscopic red wale signs.
 Hepatic venous pressure gradient (HVPG)
- ---- variceal bleeding will not occur if the
HVPG is below 12mmHg.

7. Management
Active
bleeding
episode
Prevention
of
rebleeding
Prophylactic
measure to
prevent the first
haemorrhage

8.  Non-selective ß-adrenergic antagonists such as
propranolol and nadolol.
- Propranolol 20mg bd titrated to achieve a 25%
decrement in resting pulse rate or a pulse rate
of 55-60 bpm)
 Screening endoscopy 1-2 yearly from the onset
of diagnosis of liver cirrhosis

10.  General Management:
IV access and fluid resuscitation
Prepare for blood transfusion if haemodynamic
unstable
Correction of coagulopathy and thrombocytopenia
Intubation if severe uncontrollable bleeding,
encephalopathic, inability to maintain O2 saturation
adequately and to prevent aspiration

11. Specific therapy:
 Pharmacological therapy with vasoactive drugs to arrest
the bleeding (vasopressin/it's analogue, somatostatin/it's
analogue)
a) IV Terlipressin 2 mg stat bolus and 1 mg QID for 2-5
days or;
b) IV Somatostatin 250 mcg bolus followed with 250
mcq/h infusion for 2-5 days or;
c) IV bolus Octreotide 50 mcg stat followed with IV
infusion 50 mcg/h for 2-5 days

12. Generic
name
Time to
maximum
effect
Duration of
action
Half -life
Somatostatin
Terlipressin 6 hour
Octretide
Terlipressin was not inferior to octreotide in its
effi cacy for controlling variceal bleed.

13.  Endoscopic Sclerotherapy or Endoscopic
banding or Adrenaline injection
 If bleeding uncontrolled a Minnesota tube or
Sangstaken-Blakemore tube is used.

14. a) Non-selective ß-adrenergic antagonists such as
propranolol and nadolol
b) Endoscopic sclerotherapy every 10-14 days until
the varices are obliterated (5-6 sessions)or
endoscopic variceal banding
c) Combination of pharmacological and endoscopic
management may be considered
d) Transjugular Intrahepatic Portosystemic Shunts
(TIPSS)
e) Surgical therapy (selective shunts or
devascularisation procedures)

15.  Antibiotic prophylaxis in patients with cirrhosis
 Antibiotic treatment should be continued for 7
days
 Norfloxacin 400mg bd
 OR Ciprofloxacin 500mg bd or IV 200mg bd
 OR Third generation cephalosporins (e.g.
Ceftriaxone 1g daily)

16.  Terlipressin vs. Octreotide in Bleeding EsophagealVarices as an AdjuvantTherapy With Endoscopic Band
Ligation:A Randomized Double-Blind Placebo-ControlledTrial