Variceal bleeding: Prophylaxis, treatment, and prevention

Variceal bleeding leads to significant morbidity and mortality in patients with portal hypertension. Mortality can be greater than 50% with the initial bleed and many patients develop recurrent bleeding with equal or greater mortality. Currently cirrhosis is the leading cause of portal hypertension, which is defined as a hepatic vein-portal vein gradient greater than 5 mmHg. Portal hypertension may arise from increased splanchnic blood flow due to systemic vasodilation that occurs in the hyperdynamic circulation of cirrhosis or from increased vascular resistance in intrahepatic and/or portocollateral vessels; by decreasing splanchnic blood flow, portal inflow decreases and so does portal pressure. Pharmacologic therapy consisting of nonselective β-blockers, vasopressin, and octreotide act by decreasing splanchnic blood flow, and long-acting nitrates may cause direct vasodilation of portocollateral vessels and/or decreased splanchnic blood flow. Nonselective β-blockers are the cornerstone of treatment for primary prophylaxis of bleeding, whereas vasopressin and octreotide are used for acute hemorrhaging. Two endoscopic modalities are available for control of acute bleeding and prevention of recurrent bleeding: sclerotherapy and endoscopic variceal ligation. After standard airway control and adequate fluid resuscitation, endoscopy helps localize the area of bleeding, and often in conjunction with vasopressin or octreotide can help control bleeding. Empiric antibiotics (fluoroquinolones or third-generation cephalosporins) should be started prior to endoscopy and early in the course of treatment. Sclerotherapy and band ligation along with nonselective β-blockers can help prevent recurrences of bleeding. For patients with bleeding gastric varices or uncontrollably bleeding esophageal varices, interventional radiologic procedures such as the transjugular intrahepatic portosystemic shunt (TIPS) can be used, and depending on the clinical condition and Child's classification of the patient, a surgically created portosystemic shunt may be appropriate treatment. Hopefully with emerging, new techniques and more widespread, prudent use of prophylactic drugs and endoscopy, the mortality and morbidity of variceal bleeding can be reduced.