By Dr. ArshadUllah Khan
Karachi
Variceal bleeding is one of the most alarming life-threatening complications of cirrhosis. Sixty percent of patients with cirrhosis develop esophageal varices. Thirty percent of these patients bleed from their varices within 2 years of their diagnosis, and 50% bleed at some point during their lifetime. The mortality rate for variceal bleeding is 30-50%, which is much higher than any other cause of UGIB. Patients with portal hypertension but normal liver function (eg, portal vein thrombosis, idiopathic portal hypertension, schistosomiasis) have better outcome and survival rates compared to those with liver dysfunction and other organ failure
The initial management of a patient with an acute variceal bleed involves aggressive efforts at resuscitation as previously outlined. Admit the patient to an ICU setting in which a multidisciplinary team approach can be used to treat the patient. Follow the ABCs, but avoid overhydrating the patient because volume overload can increase portal hypertension and provoke more bleeding. Since Gilbert and Vailaret coined the term portal hypertension in 1906, many therapeutic modalities have been developed to manage acute variceal hemorrhage and subsequent elective treatments for prevention of recurrent bleeding.
These treatment strategies can be classified into
(1) Pharmacologic therapy,
(2) Endoscopic therapy,
(3) Tamponade,
(4) Decompressive therapy (radiologic and surgical),
(5) Liver transplantation.
Pharmacologic therapy is described as follows:
The patient with acute variceal bleeding may initially be treated with intravenous vasopressin and nitroglycerine, somatostatin, or one of its analogs (eg, octreotide) In Europe, a newly developed prodrug called terlipressin has been used that has advantages over vasopressin. Terlipressin has a longer half-life with a biphasic vasoconstriction profile.
Endoscopy in variceal bleeding is described as follows:
The 2 main endoscopic techniques available to control variceal bleeding are endoscopic sclerotherapy and endoscopic variceal band ligation.
a) Endoscopic sclerotherapy involves injecting a sclerosing agent, such as ethanolamine or polidocanol, into the varix lumen (intravariceal) or immediately adjacent to the vessel (paravariceal) to create fibrosis in the mucosa overlying the varix, which leads to hemostasis.
b) Endoscopic band ligation Endoscopic variceal banding ligation consists of the placement of a rubber band around the varix. This technique is performed by first sucking the varix into a sheath attached to the distal end of the endoscope. Once the varix is suctioned into the sheath, a trigger device allows the deployment of a rubber band around the varix, a procedure that strangulates the varix.
c) Endoscopic Tissue glue The other available endoscopic option is the use of tissue adhesives, which are useful for both esophageal and gastric varices. Native cyanoacrylate is a liquid tissue adhesive used frequently in Europe. After injecting the substance into the varix, the blood mixes with the adhesive agent and rapidly polymerizes into a hard glue. The cyanoacrylate then plugs the lumen of the varix and creates hemostasis. Cyanoacrylate is 90% successful in achieving hemostasis in patients with acute bleeding from either gastric or esophageal varice
Balloon tamponade
The 2 most commonly used tubes are the Sengstaken-Blakemore tube and the Minnesota tube. These tubes have an esophageal balloon and a gastric balloon that are inflated to produce a tamponade effect after confirming appropriate anatomical placement. When deciding to employ this line of therapy, seriously consider endotracheal intubation to secure and protect the patient’s airway
Complications associated with balloon tamponade are as follows:
- Major complications
- Esophageal rupture
- Tracheal rupture
- Duodenal rupture
- Respiratory tract obstruction
- Aspiration
- Hemoptysis
- Tracheoesophageal fistula
- Jejunal rupture
- Thoracic lymph duct obstruction
- Esophageal necrosis
- Esophageal ulcer
- Minor complications
- Nasopharyngeal bleeding
- Chest pain
- Balloon impaction and/or migration (nausea and vomiting)
- Alar necrosis
Transjugular intrahepatic portosystemic shunt
Transjugular intrahepatic portosystemic shunt (TIPS) decompression of the portal system can be achieved through either radiologic or surgical methods. The goal is to reduce intravariceal pressure to less than 12 mm Hg. The TIPS procedure has become the most frequently employed method; because of its effectiveness, it is considered the standard of therapy for bleeding esophagogastric varices that are unrThe TIPS procedure controls variceal bleeding in more than 90% of patients. The rebleeding rate is 16-30% at 1-year follow-up, and this is most commonly related to stenosis of the intrahepatic shunt or obstruction of the stentesponsive to endoscopic and pharmacologic first-line treatment.
Surgical shunts
Surgery for bleeding esophagogastric varices is the most reliable method to control acute hemorrhage and is associated with recurrent bleeding rates of less than 10%. The goal of a surgical shunt is to effectively decrease the portal venous hypertension and its adverse effects without compromising liver function.
The widespread use of endoscopic techniques and the introduction of the TIPS procedure have made surgery a less attractive choice for acute and chronic variceal bleeding. The operative approaches for bleeding esophagogastric varices consist of 2 general concepts: (1) decompression of the high-pressure portal venous system into a low-pressure systemic venous system and (2) devascularization of the distal esophagus and proximal stomach. The following options are currently available to the surgeon:
- Portacaval shunt (end-to-side)
- Portocaval shunt (side-to-side)
- Small-diameter interposition graft
- Mesocaval shunt
- Large-diameter interposition graft
- Small-diameter interposition graft
- Distal splenorenal (ie, Warren) shunt
- Esophagogastric devascularization, esophageal transaction, and reanastomosis
- Orthotopic liver transplantation
- Splenectomy (for splenic vein thrombosis)
mortality rates of approximately 5%.
Surgical Devascularisation
One of the major controversies in the surgical management of bleeding varices has been the role of devascularization procedures. In 1973, Sugiura and Futagawa introduced their experience with a surgical technique that they developed involving gastroesophageal devascularization. The principle of the Sugiura procedure is to divide the esophageal and gastric venous plexus from the portal system, while intentionally preserving the extra esophageal systemic venous collaterals to the azygous system. The left gastric vein must be preserved during the gastric devascularization to allow drainage of the systemic venous system into the azygous vein. Initially, this was a 2-stage procedure that first involved devascularizing the upper stomach and esophagus up to the left pulmonary vein through a thoracotomy, followed by a laparotomy a few weeks later.