Variceal haemorrhage



Airway

Early RSI by senior EM/anaesthetist if:

  • Severe uncontrolled haemorrhage
  • Severe encephalopathy
  • Inability to maintain O2 sats
  • Aspiration pneumonitis

Breathing

  • High flow oxygen via reservoir bag
  • Sats monitoring
  • Check for aspiration or infective pneumonia
  • Blood gases (VBG please [risk bleeding if ABG])
  • CXR

Circulation

  • IV access- minimum 2 x 16 gauge cannulae
  • X-match 6 units of blood, ( FBC, U&Es, clotting, LFTs)
  • IV fluid – crystalloid (not colloid), then blood
  • Aim for SBP  80 - 90 mmHg [permissive ↓BP (Ref)]
  • Correct PTT
  • Central venous access (compressible site)
  • Pressure monitoring (ideally correct clotting first)
  • Catheterise (monitor hourly output)
  • Vitamin K 5-10mg slow IV and PCC 50µg/kg or FFP 15ml/kg, ± platelets

Stop the bleeding

Therapeutic

  • 2mg Terlipressin [Cochrane] in all unstable patients (beware myocardial ischaemia - Mx with GTN patch/infusion)
  • Call on call endoscopist (switchboard)
  • Scoping will confirm Dx and allow band ligation
  • Performed as soon as patient stable
  • May be performed as a life saving procedure in any critical area

Balloon tamponade (Sengstaken tube)

  • Must always be preceded by ETT & sedation
  • Reserved for severe uncontrolled haemorrhage
  • Insert the lubricated, fully deflated Sengstaken-Blakemore tube orally/nasally
  • Stop between the 50&60cm mark on the tube
  • Inflate the gastric balloon (50mL of air)
  • Confirm position with CXR, then inflate (additional 200mL of air) to 250mL total
  • Apply continuous gentle (1-2 kg) traction. It is rarely necessary to inflate oesophageal balloon
  • Mark the depth of the tube. If it moves >3cm (over next 10 min as it warms), consider the possibility of a hiatal hernia and balloon migration (repeat CXR)
  • Continue gastric port aspiration to check for bleeding below the tube
  • If bleeding continues, consider inflating the oseophageal balloon to 40mmHg

At CUH, patients presenting hypotensive (Sys BP < 100mmHg) or Hb < 10 g/dl should be admitted under the surgical team on call. (Letter).


Differential diagnosis

  • Peptic ulceration, Portal hypertensive gastropathy
  • Gastric or duodenal varices
  • Aorto-enteric fistula

Further management

  • Prophylactic antibiotics [Cochrane]
  • [NICE] (Ciprofloxacin or Ceftazidine) in confirmed variceal bleeds (Ref )


Content by Dr Íomhar O' Sullivan. Last review Dr Finn Coulter, Dr ÍOS16/11/23.