VARICEAL BLEEDING Clinical features Diagnosis and Treatment

VARICEAL BLEEDING Clinical features Diagnosis and Treatment

VARICEAL BLEEDING

  • It results from portal systemic venous collaterals when portal hypertension is more than 12 mmHg.

Clinical features,:

  • There is painless hematemesis, tachycardia and even shock.

VARICEAL BLEEDING Differential diagnosis :

  • Peptic ulcer and gastritis. Endoscopy is done for proper diagnosis.
  • Variceal bleeding is serious emergency
  • patients with varices will develop variceal hemorrhage, a major cause of morbidity and mortality in patients with cirrhosis

VARICEAL BLEEDING

VARICEAL BLEEDING Clinical features Diagnosis and Treatment


PREDICTIVE FACTORS —

  • Numerous clinical and physiologic factors are useful in predicting the risk of variceal hemorrhage in patients with cirrhosis.
  • These include:
  • Location of varices
  • Size of varices
  • Appearance of varices
  • Clinical features of the patient
  • Variceal pressure

Treatment

  • Blood transfusion Specific interventions
  • Fresh frozen plasma transfusion.
  • Admission to ICU with monitoring of central venous pressure, pulmonary capillary wedge pressure, urine output, mental status.
  • Endoscopy is advised.
  • Vasoconstrictors – somatostatin / octreotide or va­sopressin
    • Vasopressin is given 0.1 to 0.4 units / min. in IV infu­sion.
    • Bleeding often recurs after stoppage of infusion. Side effects of vasopressin are acute renal failure, hyponatremia and coronary ischemia.
    • Somatostatin is splanchnic vasoconstrictor. It is given 250IJg bolus followed by 250 IJg / hour.
    • Octreotide is given 50 – 100 IJg/hour. These are pre­ferred to vasopressin.
    • Nitroglycerin drip or isosorbide-di-nitrate are given to prevent side effects.
    • Balloon tamponade is done to stop bleeding Endoscopic ligation or sclerotherapy of varices may be done to check and pevent bleeding.
  • Endoscopic variceal Iigation (EVL)
    •  is the best method where circular rings are used to ligate the varices.
  • Surgical treatment
    •  is last resort because of high mortality.
    • In TIPS (Trans Jugular Intrahepatic Portosystemic Shunt) a metal stent is used to create a portocaval channel. This is used in refractory bleeding only.
    • Liver transplantation is being increasingly done nowa­days.
    • Gastric fundal bleeding is more difficult to manage.

Prevention of first haemorrhage  :

Prevention of recurrent haemorrhage  :

  • · Endoscopic band ligation
  • · Beta blockers
  • · Portosystemic shunt surgery

Portal hypertensive gastropathy

  • · A congestive gastropathy occurs due to venous hypertension.
  • · Mucosa becomes friable.
  • · Beta blockers and proton pump inhibitors are given.
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