Gastroenterology and Hepatology

Varices

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Management of Varices:

Pathophysiology:

  1. increased resistance to flow mostly due to an architectural distortion of the liver secondary to fibrous tissue and regenerative nodules.
  2. active intrahepatic vasoconstriction that accounts for 20%-30% of the increased intrahepatic resistance
  3. increase in portal venous inflow that results from splanchnic arteriolar vasodilatation

 

HVPG

 

Oesophageal Varix

Prevalence is about 40% in Child’s A and 85% in Child’s C

Those without varices will develop them at a rate of 8% a year especially if >10mmHg HVPG

Small varix to big varix also at about 8% a year

 

Haemorrhages occur at a rate of 5-15% a year

Bleeding spontaneously stops 40% of the time

Mortality 20% at 6 weeks

If bleeding untreated, 60% will rebleed in 1-2 years

 

Gastric Varix

5-33% prevalence with incidence of bleeding 25% in 2 years

 

Predicting Variceal Bleeding

PREDICTING VARICEAL HEMORRHAGE

  

Red Wale Marks

Child-Pugh Class

  

A

B

C

  

F1

F2

F3

F1

F2

F3

F1

F2

F3

  

-

6

10

15

10

16

26

20

30

42

  

+

8

12

19

15

23

33

28

38

54

  

+++

16

23

34

28

40

52

44

60

76

  

Based on data from DeFranchis R: Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. N Engl J Med 319:983, 1988.

  


Screening and surveillance schedule:

At time of cirrhosis diagnosis, must have an OGDS

Compensated cirrhosis and no varix on surveillance, repeat in 3 years

Decompensated cirrhosis and no varix on surveillance, repeat in 1 year

Small varix and not bled, if compensated 2 yearly, if decompensated, yearly

Medium/Large Varix: 6-12 monthly surveillance

If banding done, repeated every 2-3 weeks until obliteration, then first surveillance at 3 months after obliteration, then every 6-12 months

 

 

AIM of NSBB

<12 mm Hg HVPG eliminate risk of bleeding

>20% or even >10% reduction reduces significance chance of bleeding

HR 55-60bpm

 

PRIMARY PROPHYLAXIS

Cirrhosis and no varices:

Screen 3 yearly (compensated) and yearly (decompensated)

No evidence NSBB will prevent varices formation

 

Cirrhosis, small varix and not bled:

Chances to bleed 7% in 2 years but if start NSBB 2% in 2 years

Progression to large varices 37% in 3 years but if start NSBB 11% in 3 years

If start NSBB when varix is small, chances to bleed 12% in 5 years, if start NSBB when varix is large, 22% in 5 years

 

Therefore, NSBB must be started. EVL not recommended

OGDS yearly if decompensated

2 yearly if compensated and no NSBB

No recommendation if compensated and started NSBB

 

Cirrhosis and Medium/large varix that has not bled

Risk of first bleed is 30% (no NSBB) vs 14% (on NSBB). NNT is 10

EVL equivalent to propranolol in preventing the first variceal hemorrhage.

Since both NSBB and EVL are effective in preventing first variceal hemorrhage, decision should be based on patient characteristics and preferences, local resources and expertise. No difference in mortality but first bleed earlier with NSBB.

EVL if presence of red wale signs otherwise NSBB??

 

NOT recommended for primary prophylaxis

ISMN NSBB combo

NSBB Spironolactone combo

ISMN mono

Shunt surgery

Sclerotherapy

 

 

ACUTE VARICEAL BLEED

Fluid and blood resuscitation as general measure.

Avoid vigorous saline resuscitation

Hb approximately 8g/dL

FFP Vit K platelets in those with significant coagulopathy or thrombocytopenia.

rFVIIa small benefit in Child’s B / C

 

Antibiotic prophylaxis with Norfloxacin 400mg bd or Ceftriaxone 1g daily 5-7 days

 

Terlipressin 2mg 4 hourly titrate to 1mg 4 hourly once bleeding controlled (ECG daily) for 5 days

OR

Octreotide 50mcgm bolus infusion 50mcgm/hr (5 days total)

 

Sengstaken Blackmore tube: 24 hours maximum. 5 min break every 6 hours to prevent necrosis

 

PPI 40mg daily for 9 days to reduce size of post banding ulcer

 

Follow up post Acute Variceal Bleed and Secondary Prophylaxis

Repeat OGDS every 2-3 weeks until obliteration, then first surveillance at 3 months after obliteration, then every 6 months

NSBB

TIPS if still recurrent even after EVL + NSBB