Variceal bleeding: Prophylaxis, treatment, and prevention

Variceal bleeding leads to significant morbidity and mortality in patients with portal hypertension. Mortality can be greater than 50% with the initia l bleed and many patients develop recurrent bleeding with equal or greater mortality. Currently cirrhosis is the leading cause of portal hypertension, which is defined as a hepatic vein-portal vein gradient greater than 5 mmH g. Portal hypertension may arise from increased splanchnic blood flow due t o systemic vasodilation that occurs in the hyperdynamic circulation of cirr hosis or from increased vascular resistance in intrahepatic and/or portocol lateral vessels; by decreasing splanchnic blood flow, portal inflow decreas es and so does portal pressure. Pharmacologic therapy consisting of nonsele ctive P-blockers, vasopressin, and octreotide act by decreasing splanchnic blood flow, and long-acting nitrates may cause direct vasodilation of porto collateral vessels and/or decreased splanchnic blood flow. Nonselective P-b lockers are the cornerstone of treatment for primary prophylaxis of bleedin g, whereas vasopressin and octreotide are used for acute hemorrhaging. Two endoscopic modalities are available for control of acute bleeding and preve ntion of recurrent bleeding: sclerotherapy and endoscopic variceal ligation . After standard airway control and adequate fluid resuscitation, endoscopy helps localize the area of bleeding, and often in conjunction with vasopre ssin or octreotide can help control bleeding. Empiric antibiotics (fluoroqu inolones or third-generation cephalosporins) should be started prior to end oscopy and early in the course of treatment. Sclerotherapy and band ligatio n along with nonselective P-blockers can help prevent recurrences of bleedi ng. For patients with bleeding gastric varices or uncontrollably bleeding e sophageal varices, interventional radiologic procedures such as the transju gular intrahepatic portosystemic shunt (TIPS) can be used, and depending on the clinical condition and Child's classification of the patient, a surgic ally created portosystemic shunt may be appropriate treatment. Hopefully wi th emerging, new techniques and more widespread, prudent use of prophylacti c drugs and endoscopy, the mortality and morbidity of variceal bleeding can be reduced.