AKT · Gastroenterology/GI bleeding

Variceal disease

Portosystemic collateral varices from portal hypertension (cirrhosis) → catastrophic bleeding

Overview

Dilated portosystemic collateral veins (oesophageal/gastric varices) that form when portal hypertension (usually cirrhosis) drives blood through collaterals. They can bleed catastrophically. Acute variceal haemorrhage is managed with resuscitation, terlipressin + prophylactic antibiotics and endoscopic band ligation; primary/secondary prevention uses non-selective beta-blockers and banding. A medical emergency with high mortality.

Recognise

Large-volume HAEMATEMESIS ± melaena in a patient with chronic liver disease/portal hypertension (stigmata: jaundice, ascites, spider naevi, splenomegaly)
Often haemodynamic compromise; may precipitate hepatic encephalopathy
Gastric varices (with isolated splenic vein thrombosis) and other portosystemic collaterals (caput medusae, rectal varices)

Red flags

Active variceal haemorrhage → major haemorrhage protocol; high mortality
Decompensation/encephalopathy/SBP precipitated by the bleed

Differentials & how to tell them apart

Peptic ulcer bleedNSAID/H. pylori; treated with PPI + endoscopic therapy, not terlipressin

Mallory-Weiss tearretching, usually self-limiting

Portal hypertensive gastropathydiffuse oozing rather than a focal varix

Investigations

As for upper GI bleed: resuscitate, FBC/U&Es/LFTs/clotting, crossmatch. Urgent ENDOSCOPY (diagnostic + band ligation). Assess liver disease severity.

Management

Resuscitate + terlipressin + antibiotics + endoscopic band ligation

1Resuscitate (fluids/blood, restrictive transfusion, correct coagulopathy). Give TERLIPRESSIN and PROPHYLACTIC ANTIBIOTICS early. Urgent endoscopy with band ligation.Gate: Terlipressin + antibiotics are given BEFORE/with endoscopy in suspected variceal bleeding (antibiotics reduce mortality); balloon tamponade or TIPS is the rescue for uncontrolled bleeding
2Secondary prevention: non-selective beta-blocker (propranolol/carvedilol) + repeat banding; TIPS for refractory/recurrent bleeding; primary prevention (NSBB or banding) for medium/large varices found on surveillance.

Terlipressin (vasopressin analogue) — splanchnic vasoconstriction — give EARLY in suspected variceal bleed

Prophylactic antibiotics — reduce infection/SBP and mortality — give to all with a variceal bleed

Endoscopic band ligation (± sclerotherapy; glue for gastric varices) — haemostasis

Balloon tamponade (Sengstaken) / TIPS — rescue for uncontrolled bleeding

Key points

Big haematemesis + chronic liver disease = variceal bleed → terlipressin + antibiotics + banding. Antibiotics save lives here. NSBB ± banding for prevention; TIPS/tamponade as rescue. (UGIB resuscitation is shared with acute care.)

Monitor & prognosis

Haemodynamics, rebleeding, liver decompensation; secondary prophylaxis.

High mortality with each bleed; depends on liver function.

Source: NICE CG141; BSG/Baveno