Variceal bleeding in cirrhotic patients

Maxime Mallet, Marika Rudler, Dominique Thabut, Maxime Mallet, Marika Rudler, Dominique Thabut

Abstract

Variceal bleeding is one of the major causes of death in cirrhotic patients. The management during the acute phase and the secondary prophylaxis is well defined. Recent recommendations (2015 Baveno VI expert consensus) are available and should be followed for an optimal management, which must be performed as an emergency in a liver or general intensive-care unit. It is based on the early administration of a vasoactive drug (before endoscopy), an antibiotic prophylaxis and a restrictive transfusion strategy (hemoglobin target of 7 g/dL). The endoscopic treatment is based on band ligations. Sclerotherapy should be abandoned. In the most severe patients (Child Pugh C or B with active bleeding during initial endoscopy), transjugular intrahepatic portosystemic shunt (TIPS) should be performed within 72 hours after admission to minimize the risk of rebleeding. Secondary prophylaxis is based on the association of non-selective beta-blockers (NSBBs) and repeated band ligations. TIPS should be considered when bleeding reoccurs in spite of a well-conducted secondary prophylaxis or when NSBBs are poorly tolerated. It should also be considered when bleeding is refractory. Liver transplantation should be discussed when bleeding is not controlled after TIPS insertion and in all cases when liver function is deteriorated.

Keywords: cirrhosis; endoscopic treatment; liver transplantation; non-selective beta-blockers; transjugular intrahepatic portosystemic shunt; variceal bleeding.

Figures

Figure 1.
Figure 1.
Algorithm for the management of acute variceal bleeding.
Figure 2.
Figure 2.
Endoscopic band ligation. (A) Normal esophagus. (B) and (C) Large esophageal varices with red wale marks. (D) Post-banding necrosis of varicose tissue.

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