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 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  :

• · Beta blockers
• · Banding of oesophageal varices

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.