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Variceal Hemorrhage

By ACEP Now | on February 1, 2011 | 0 Comment
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One treatment modality that likely will remain a salvage therapy is balloon tamponade. A rescue therapy for actively exsanguinating patients, the Sengstaken-Blakemore or Minnesota tube, when inflated within the esophagus, can control variceal bleeding in up to 90% of cases. The complication rate, however, approaches 30%, including aspiration pneumonia, airway obstruction, esophageal perforation, or mucosal injury. It is therefore recommended for use only by experienced clinicians in emergent situations, and after endotracheal intubation. Rebleeding following balloon deflation occurs in approximately 50% of cases.7

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ACEP News: Vol 30 – No 02 – February 2011

Recombinant factor VIIa has been studied as an adjunct therapy but so far has not shown sufficient utility to warrant routine use. Intended to improve coagulopathy during active bleeding, factor VIIa has not been shown to control bleeding or prevent rebleeding in randomized, controlled trials. There does appear to be an improvement in 6-week mortality. Given the cost involved and lack of firm evidence base, this drug should be used only as salvage therapy.6

CME Questionnaire Available Online

The CME test and evaluation form based on this article are located online at www.ACEP.org/focuson.

The participant should, in order, review the learning objectives, read the article, and complete the CME post-test/evaluation form to receive 1 ACEP Category 1 credit and 1 AMA/PRA Category 1 credit. It should take approximately 1 hour to complete. You will be able to print your CME certificate immediately.

The credit for this CME activity is available through Jan. 31, 2014.

Conclusion

Despite significant improvement in mortality in the last 25 years, variceal hemorrhage remains a deadly condition that can be difficult to manage in the emergency department setting. Keys to management include recognizing the poor prognosis and beginning treatment promptly, knowing the key pharmacologic interventions and coordinating care early with GI or surgical services as appropriate. One center found that prophylactic antibiotics were given to only 25% of variceal hemorrhage patients, while beta-blockers were given to only 24% of those with no contraindication, illustrating the need for improved communication and education.27 Informed emergency physicians are in an excellent position to make a difference in the care of these patients.

References

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  2. Jutabha R and Jensen DM. Management of upper gastrointestinal bleeding in the patient with chronic liver disease. Med Clin North Am. 1996;80(5):P1035-67.
  3. Peter DJ and Dougherty JM. Evaluation of the patient with gastrointestinal bleeding. Emerg Med Clin North Am. 1999;17(1):239-61.
  4. Thabut D and Bernard-Chabert B. Management of acute bleeding from portal hypertension. Best Pract Res Clin Gastroenterol. 2007;21(1):19-29.
  5. Garcia-Tsao G and Bosch J. Management of varices and variceal hemorrhage in cirrhosis. N Engl J Med. 2010;362(9):823-32.
  6. Bendtsen F, et al. Treatment of acute variceal bleeding. Dig Liver Dis. 2008;40:328-36.
  7. Sass DA and Chopra KB. Portal hypertension and variceal hemorrhage. Med Clin North Am. 2009;93:837-53.
  8. Krige JEJ, et al. Predictive factors for rebleeding and death in alcoholic cirrhotic patients with acute variceal bleeding. World J Surg. 2009;33:2127-35.
  9. Goulis J, et al. Bacterial infection is independently associated with failure to control bleeding in cirrhotic patients with gastrointestinal hemorrhage. Hepatology. 1998;27:1207-12.
  10. Jun CH, et al. Antibiotic prophylaxis using third-generation cephalosporins can reduce the risk of early rebleeding in the first acute gastroesophageal variceal hemorrhage. J Korean Med Sci. 2006;21:883-90.
  11. Palmer K. Acute upper gastrointestinal hemorrhage. Br Med Bull. 2007;83:307-24.
  12. Abraldes JG and Bosch J. The treatment of acute variceal bleeding. J Clin Gastroenterol. 2007;41(3):S312-7.
  13. Bambha K, et al. Predictors of early re-bleeding and mortality after acute variceal hemorrhage in patients with cirrhosis. Gut. 2008;57:814-20.
  14. Bhatti N, et al. Myocardial infarction in critically ill patients presenting with gastrointestinal hemorrhage. Chest. 1998;114:1137-42.
  15. Witting MD, et al. Usefulness and validity of diagnostic nasogastric aspiration in patients without hematemesis. Ann Emerg Med. 2004;43(4):525-32.
  16. Lee SD and Kearney DJ. A randomized controlled trial of gastric lavage prior to endoscopy for acute upper gastrointestinal bleeding. J Clin Gastroenterol. 2004;38(10):861-5.
  17. Garcia-Tsao G, et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46(3):922-38.
  18. Thalheimer U, et al. Infection, coagulation, and variceal bleeding in cirrhosis. Gut. 2005;54:556-63.
  19. Coffin B, et al.Erythromycin improves the quality of EGD in patients with acute upper GI bleeding. Gastrointest Endosc. 2002;56:174-9.
  20. Frossard JL, et al. Erythromycin intravenous bolus infusion in acute upper gastrointestinal bleeding. Gastroenterology. 2002;123:17-23.
  21. Winstead NS and Wilcox CM. Erythromycin prior to endoscopy for acute upper gastrointestinal haemorrhage. Aliment Pharmacol Ther. 2007;26:1371-7.
  22. Yan BM and Lee SS. Emergency management of bleeding esophageal varices: drugs, bands or sleep? Can J Gastroenterol. 2006;20(3):165-70.
  23. Cheung J, et al. Urgent vs. non-urgent endoscopy in stable acute variceal bleeding. Am J Gastroenterol. 2009;104:1125-9.
  24. Sarin N, et al. Time to endoscopy and outcomes in upper gastrointestinal bleeding. Can J Gastroenterol. 2009;23(7):489-93.
  25. Garcia-Pagan J, et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med. 2010;362(25):2370-9.
  26. Orloff MJ, et al. Randomized trial of emergency endoscopic sclerotherapy versus emergency portacaval shunt for acutely bleeding esophageal varices in cirrhosis. JACS. 2009;209:25-40.
  27. Singh H, et al. An assessment of endoscopic and concomitant management of acute variceal bleeding at a tertiary care centre. Can J Gastroenterol. 2007;21(2):85-90.

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Topics: Abdominal and GastrointestinalAirway ManagementAllied Health ProfessionalsAntibioticBlood PressureCMECritical CareDeathDiagnosisEducationEmergency MedicineEmergency PhysicianENTHematologyImaging and UltrasoundProcedures and SkillsRadiographyRadiologyTransfusionTrauma and Injury

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