Appropriate treatment for acute variceal bleeding

As a clinical pharmacist, you must be kept up to date. One-third of patients with varices will have variceal bleeding, the most life-threatening complication of cirrhosis. Expect patients to be resuscitated with fluids and blood if needed, then to have an endoscopy within 12 hours for esophageal banding.

Start an octreotide bolus followed by an infusion. Combining octreotide with endoscopic intervention seems to control bleeding and prevent early rebleeding better than either treatment alone. But there's no proof octreotide improves mortality. Stop after 5 days, or possibly sooner if bleeding is controlled.

NPS-adv

Add antibiotic prophylaxis. These patients are at high infection risk, especially for spontaneous bacterial peritonitis. Adding antibiotics is also linked to decreased rebleeding and mortality. Use up to 7 days of ceftriaxone, or a quinolone depending on local gram-negative resistance. Consider stopping once octreotide is stopped. Stay alert for proton pump inhibitors (PPIs). A PPI drip is often used while working up a GI bleed. But stop the drip if varices are the only source of bleeding. There's no proof PPIs add benefit to octreotide. If a PPI is started for banding-related ulcers, limit to 10 days.

Start propranolol or nadolol after octreotide is stopped. These nonselective beta-blockers decrease portal pressure and prevent rebleeding. Titrate doses to a heart rate of 55 to 60 beats/min. Expect patients who rebleed despite medications and banding to need a transjugular intrahepatic portosystemic shunt (TIPS) procedure to control portal pressure. These patients won't need a beta-blocker. At discharge, ensure patients have close follow-up, since rebleeding is common. Plus a repeat endoscopy and banding are needed within weeks.

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References

1. Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology. 2017 Jan;65(1):310-335.
2. Tripathi D, Stanley AJ, Hayes PC, Patch D, Millson C, Mehrzad H, Austin A, Ferguson JW, Olliff SP, Hudson M, Christie JM; Clinical Services and Standards Committee of the British Society of Gastroenterology. U.K. guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut. 2015 Nov;64(11):1680-704.
3. Lo EA, Wilby KJ, Ensom MH. Use of proton pump inhibitors in the management of gastroesophageal varices: a systematic review. Ann Pharmacother. 2015 Feb;49(2):207-19.
4. Bañares R, Albillos A, Rincón D, et al. Endoscopic treatment versus endoscopic plus pharmacologic treatment for acute variceal bleeding: a meta-analysis. Hepatology. 2002 Mar;35(3):609-15.

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