Esophageal Variceal Bleeding in the Emergency Department

Mon, 01/30/2017 - 8:20am
Author: 
Eric Gruber, MD
Editor: 
Richard Byrne, MD

 

Prognosis is poor:

 

  • 16% mortality overall, 15-30% for first-time bleeders

  • 30-60% with re-bleeding after banding, most often within the first 10 days.

    Patients with history of alcohol abuse are not only at risk for variceal bleeding, but also bleeding from gastric ulcers, Mallory Weiss tears, and erosive esophagitis.

    Bright-red or maroon-colored rectal bleeding originates from an upper GI source 14% of the time.

    Vitals signs are vital, but younger patients are often able to compensate despite significant bleeding and may even have paradoxical responses.

 

  • Paradoxical bradycardia can be seen with significant blood loss.

  • Mild tachypnea and decreased pulse pressure may be clues to impending hemodynamic instability.

    BUN/Cr ratio > 30 is highly suggestive of upper GI bleeding, as digested and re-absorbed hemoglobin will raise the BUN.

    Despite common misperception, insertion of a nasogastric tube will not provoke further esophageal variceal bleeding. While there is no evidence behind use of NG tube and prediction of bleeding location or mortality benefit, there is evidence that supports improvement of visualiztion of bleeding source during endoscopy.

    The initial treatment is similar to resuscitation for any hemorrhagic shock, i.e. secure the airway as needed with administration of blood products for active bleeding/failure to improve signs of perfusion after administration of 2 L of crystalloid. Secondary management aims to stop the bleeding:

 

  • Endoscopy (banding ligation is best, followed by sclerotherapy, tissue adhesive).

  • Octreotide bolus and then drip: decreased bleeding in 80% of cases, although no clear mortality benefit (should be continued for 24-48 hours).

  • Proton pump inhibitor (not to treat variceal bleeding, but UGIB often undifferentiated prior to EGD).

  • Beta blockers; propanolol is typically used. Not for acute bleeding, but to prevent rebleeding.

  • Antibiotic prophylaxis (ceftriaxone or fluoroquinolone). Antibiotic Use in Cirrhotic Patients with Upper GI Bleeds.

  • Blakemore balloon tamponade.

  • Interventional radiology: TIPS procedure (transjugular intrahepatic portosystemic shunt) or transjugular variceal embolization.

  • Emergent surgery for direct portocaval shunting or esophageal transaction/devascularization.

    References:

 

1.    “Upper Gastrointestinal Bleeding.” Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e, Chapter 78

 

2.    “EBM Oesophagogastric Varices” by Mike Cadogan on Life in the Fastlane http://lifeinthefastlane.com/ebm-varices

“Esophagogastric Devascularization” by Nikolas Sikalas on Medscape http://emedicine.medscape.com/article/1895379-overview>