EMERGENCY MANAGEMENT OF VARICEAL BLEEDING

The main aetiology of acute gastrointestinal haemorrhage in cirrhotic patients is variceal bleeding. Prognosis is determined by early or lat e rebleeding rates and the severity of underlying liver disease, mostl y estimated by Child Pugh score. Diagnosis and therapy of variceal ble eding is currently based on endoscopic sclerotherapy and more recently on banding ligation, However, the management of acute variceal bleedi ng remains controversial and vasoactive drugs are an alternative treat ment, At present, most of these studies showed encouraging but conflic ting results. These trials show that the cyclic octapeptide analogue ( octreotid) of somatostatin or the triglycyl analogue (terlipressin) of vasopressin are safer and more effective than their natural drugs res pectively.Clinically, drug choice depends on four factors: results of trials comparing vasoactive treatment to classical sclerotherapy: comp arison of these two kinds of treatment show similar results concerning haemostatic rate as well as mortality especially for somatostatin or its synthetic analogue; results of trials comparing synthetic analogue of vasopressin to cyclic analogue of somatostatin in variceal bleedin g: current study designs demonstrate an arithmetic difference (p=0.06) with a better early haemostatic rate after octreotid associated with comparable final haemostasis (after 24 hours) and mortality; results o f combination of both treatments (i.e. sclerotherapy associated with v asoactive drug versus sclerotherapy): such association decreases varic eal rebleeding without improvement of survival rate; and finally, impo rtance of adverse drug effects on hepatic and renal functions: few stu dies show scanty and conflicting adverse drug effect especially on fre e water clearance which must be studied by further clinical trials to confirm their benefit in emergency management of variceal bleeding.