gastrointestinal disorders
Varices
Treatment of Varices
Airway management and fluid resuscitation, including blood transfusion if needed Endoscopic banding (sclerotherapy second choice) IVoctreotide Sometimes antibiotics Possibly a transjugular intrahepatic portosystemic shunting (TIPS) procedure Airway Establishment and Control and Patients with known cirrhosis with GI bleeding are at risk of bacterial infection and should receive antibiotic prophylaxis with norfloxacin orceftriaxone. If a patient taking a nonselective beta-blocker (eg, propanolol) has active hemorrhage and hypotension, the beta-blocker should be stopped. (a synthetic analog of somatostatin, which may also be used) should be given ( Treatment references ). If bleeding continues or recurs despite these measures, emergency techniques to shunt blood from the portal system to the vena cava can lower portal pressure and diminish bleeding. A TIPS procedure is the emergency intervention of choice. TIPS is an invasive radiologic procedure in which a guidewire is passed from the vena cava through the liver parenchyma into the portal circulation. The resultant passage is dilated by a balloon catheter, and a metallic stent is inserted, creating a bypass between the portal and hepatic venous circulations. Stent size is crucial. If the stent is too large, portal-systemic encephalopathy results because of diversion of too much portal blood flow from the liver. If the stent is too small, it is more likely to occlude. Surgical portacaval shunts, such as the distal spleno-renal shunt, work by a similar mechanism but are more invasive and have a higher immediate mortality. Mechanical compression of bleeding varices with a Sengstaken-Blakemore tube or one of its variants causes considerable morbidity and should not be used as primary management. However, such a tube may provide life-saving tamponade pending decompression with a TIPS or surgical procedure. The tube is a flexible nasogastric tube with one gastric balloon and one esophageal balloon. After insertion, the gastric balloon is inflated with a fixed volume of air, and traction is applied to the tube to pull the balloon snugly against the gastroesophageal junction. This balloon is often sufficient to control bleeding, but, if not, the esophageal balloon is inflated to a pressure of 25 mm Hg. The procedure is quite uncomfortable and may result in esophageal perforation and aspiration; thus, endotracheal intubation and IV sedation are often recommended. More recently, expandable metal esophageal stents have been used successfully to tamponade bleeding. Liver transplantation can also decompress the portal system but is a practical option only for patients already on a transplant list. Treatment (with beta-blockers and nitrates) is discussed elsewhere. Splenectomy is done to treat gastric variceal bleeding due to splenic vein thrombosis (sometimes a sequela of pancreatitis). 1.Mohanty A, Kapuria D, Canakis A, et al: Fresh frozen plasma transfusion in acute variceal haemorrhage: Results from a multicentre cohort study.Liver Int41(8):1901–1908, 2021. doi: 10.1111/liv.14936 2.Boregowda U, Umapathy C, Halim N, et al: Update on the management of gastrointestinal varices.World J Gastrointest Pharmacol Ther10(1):1–21, 2019. doi: 10.4292/wjgpt.v10.i1.1 