Saudi Journal of Gastroenterology
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Year : 1995  |  Volume : 1  |  Issue : 1  |  Page : 25-30
Variceal bleeding: Management options

Department of Medicine, College of Medicine, King Saud University, P.O. Box 2925, Riyadh 11461, Saudi Arabia

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Portal hypertension with esophageal varices represents an important source of upper gastrointestinal bleeding. Variceal bleeding is associated with high rebleeding and mortality rates. Various treatment modalities are effective in control of bleeding. Endoscopic Sclerotherapy (ES) is the standard method for management of acute variceal bleeding alone or in combination with vasoactive drugs. Alternative methods are considered in case of sclerotherapy failure. Portosystemic shunt operation is complicated by systemic encephalopathy. Therefore, it is replaced by other surgical procedures. These include esophageal stapled transection, splenectomy with devascularization, distal splenorenal shunt (DSRS), DSRS combined with pancreatic disconnection, narrow diameter mesocaval (NDMC) or portocaval (NDPC) shunts and liver transplantation . Recently. transjugular intrahepatic portosystemic stent­shunting (TIPSS) has been introduced in the management of patients with refractory variceal bleeding waiting for liver transplanation.

How to cite this article:
Al Mofleh IA, Al Rashed RS, Al Amri SM. Variceal bleeding: Management options. Saudi J Gastroenterol 1995;1:25-30

How to cite this URL:
Al Mofleh IA, Al Rashed RS, Al Amri SM. Variceal bleeding: Management options. Saudi J Gastroenterol [serial online] 1995 [cited 2022 Jul 6];1:25-30. Available from:

In Saudi Arabia and Jordan, bleeding from esophageal varices complicating portal hyperten­sion is prevalent and accounts for 10-40% of upper gastrointestinal bleeding. [1],[2],[3],[4]

Approximately one third of patients with liver cirrhosis bleed from esophageal varices. [5] The outcome of the initial bleeding is influenced by Child-Pugh's grade, the quantity of blood loss, the presence of ascites, bilirubin and blood urea nitro­gen (BUN) plasma level [6] Bleeding from esophageal varices is associated with 50% mortal­ity rate [7] and a high rebleeding rate, 30 and 70% at six weeks and one year respectively. [8] Rebleed­ing is well correlated with the liver function and is more prevalent in patients with Child grade C. [9]

Various therapeutic options are available for the management of bleeding esophageal varices. [Table - 1] Pharmacological agents, balloon tam­ponade, endoscopic sclerotherapy, endoscopic variceal ligation and surgical approaches are used with variable success rates.

   Pharmacological agents Top

Vasopressin is a drug with a constricting effect on the splanchnic circulation and thus lowering the portal pressure. [10] It controls bleeding in 50% patients, however 45% rebleed. [11],[12] Drug adverse effects are dose related and include ischemia, bradycardia, hypertension and decreased hepatic oxygen consumption. Serious cardiac adverse effect occur in approximately 15% of patients. [13] Vasopressin is administered by continuous intravenous infusion (0.4 u/min). The dose is adjusted according to the hemostatic and adverse effects. It is reduced by 0.1 u/min every 6-12 hours after bleeding cessation. [14] Adverse reactions can be prevented or reduced by the simultaneous use of nitroglycerin. [15],[16],[17]

Terlipressin is a longacting vasopressin analogue with similar action. It has been found to be superior to placebo in regard of hemostasis and survival. [11] In combination with nitroglycerin, terlipressin was found to be as effective as balloon tamponade in bleeding control. [18]

Somatostatin induces vasoconstriction of the splanchnic arterioles with a reduction/of the portal flow and the azygos venous blood flow. [19],[20] Somatostatin, in contrast to vasopressin, does not cause systemic vasoconstriction, [20],[21],[22],[23] however, it is expensive with equivocal hemostatic effect. It has been compared with placebo with controver­sial results. [21],[22]

Octreotide, a somatostatin analogue, has signif­icant and prolonged reduction of the portal and hepatic venous circulation in experimental ani­mals. [24] In cirrhotic patients with portal hyperten­sion, octreotide is similar to somatostatin in reduction of the wedged hepatic vein pressure probably due to its constricting effect on the splan­chnic orterioles. [25] It also significantly reduces the azygos venous blood flow [26] without systemic hemodynamic effects. [27] In their preliminary results Jenkins et al. found octreotide as effective as sclerotherapy in the early control of variceal bleeding. [28] Furthermore, octreotide hemostatic effect was comparable to balloon tamponade. [27]

   Balloon tamponade Top

Balloon tamponade is a simple method, easily accessable and non expensive device that controls variceal bleeding by mechanical compression in approximately 90% of patients. [29],[30] Although this technique has a temporary effect and is com­plicated by a high rebleeding rate, upto 60% after balloon deflation, it is still indicated in massive variceal bleeding and when therapeutic endos­copic techniques are not available.

   Endoscopic methods Top

Endoscopic sclerotherapy is a fairly old technique which was firstly reported 1939 by Crafoord and Frenkner using a rigid scope. [30] This method has become popular with the development of fiberscope and the high success rate reported in 1973 by Johnston and Rodgers. [31] Nowadays ES is the mainstay of treating bleeding esophageal varices. [32],[34] The most commonly used slerosing agents are polidocanol, ethanolamine oleate, sodium tetradecyl sulfate and morrhurate with no definite superiority of one or the other agent. [35] Other sclerosing agents include absolute ethanol, 50% dextrose with sodium chloride and 15% sodium chloride. [36]

Hemostasis is achieved in approximately 90% of patients undergoing sclerotherapy. [32] How­ever it is associated with a high rebleeding rate before completion of eradication. Paravariceal, intravariceal and combination of both techniques are used for hemostasis of bleeding varices. [34],[37] The efficacy of the paravariceal injection is unsatisfactory and therefore, uncommonly used. [30] Injection of sclerosing agent is associated with inflammatory reaction and formation of edema that induces a mechanical tamponade. This effect decreases after 3-5 days with possible rebleeding. A second injection performed with this period of time may prevent or reduce early rebleeding. [11] The timing of first sclerotherapy has been investigated by Westaby et al. They found a significant improvement of hemostasis when immediate sclerotherapy was performed, compared to sclerotherapy after 12 hours of vas­opressin and nitroglycerin infusion. [33]

Sclerotherapy is associated with a number of esophageal, respiratory and systemic complica­tions. [Table - 2] However the rate of serious com­plications does not exceed 10%. Complications can be reduced by improvement of the technical expertise and the control of the injected quantity of sclerosing agent. [30] Acute variceal hemorrhage is managed successfully with ES in majority of patients.

Alternative measures (Tables) are indicated in the following conditions: a) Failure to control bleeding after two sclerotherapy sessions, [38] b) rebleeding within 48 hours [11] c) two recurrences during the same hospitalization, [11],[39] d) rebleed­ing from gastric varices [11],[39] and e) bleeding from ulcer complicating sclerotherapy or balloon tam­ponade. [39]

Endoscopic variceal ligation (EVL), was intro­duced in 1986 by Stiegmann et al. using small, elastic 0 rings for variceal ligation. [40] Since then several studies have compared EVL with sclerotherapy. Patient treated with EVL have sig­nificantly lower morbidity and mortality. [41] Gim­son et al. found EVL significantly better than sclerotherapy in regard of the obliteration time, number of endoscopic sessions and rebleeding rate. Both techniques has a similar effect on hemostasis and obliteration. Although EVL is proven to be safe, [41],[42] some complications were reported recently in form of bleeding or perfora­tion related to the use of overtube [43],[44],[45] or to the ulcer formation with massive bleeding or stric­ture. [46]

   Tissue Adhesives Top

Liquid tissue adhesives were also used for hemostasis with a decline of the rebleeding rate compared to polidocanol, 12.2 and 30.5%, respectively. [37]

   Transjugular intrahepatic portosystemic stent­shunting (TIPSS) Top

This method was described in 1969 in experi­mental animal by Rosch et al. [47] Colapinto et al. 1982 reported the first application in man. [48] The recent introduction of metallic expandable stents has encouraged further use of this technique in human and was first reported in 1989 by Richter et al. [49] Ring et al. reported 100% hemostasis with a significant reduction of the mean portal pressure with complications in patients with refractory variceal bleeding scheduled for liver transplanta­tion. [50] However, procedure related complica­tions inform of septicemia and fatal intra­peritoneal hemorrhage were reported by other authors. [51] Furthermore, rebleeding due to occlu­sion and encephalopathy may still occur in up to 15 and 30% respectively. [52],[53]

   Surgical Procedures Top

Before the ara of sclerotherapy, portosystemic shunt (PSS) was the most frequently used technique to treat acute variceal bleeding. Nowa­days surgical options are considered in case of sclerotherapy failure as defined above. Although rebleeding is reduced by PSS it is considered as a major surgery complicated by portosystemic encephalopathy and associated with a high mor­tality rate. [53]

Distal splenorenal shunt (DSRS) as an elective surgery with a less frequent post- shunt encephalopathy has nowadays replaced PSS. [5],[55],[57]

Another effective and simple method for treat­ment of acute variceal bleeding is the esophageal staple transection which controls bleeding in 100% of patients and does not interfere with the hepatic perfusion. [11] The drawback of this proce­dure is the revascularization and rebleeding. [5]

Devascularization and Splenectomy (Hassab) with or without esophageal transection is an effec­tive method in managing variceal bleeding. [58]

Newer surgical shunts preserve the portal per­fusion and therefore, in contrast to PSS have no influence on the liver hemodynamics and func­tion. These techniques includes a combination of DSRS with a total splenopancreatic disconnec­tion, narrow diameter mesocaval (NDMC) or portocaval (NDPC) shunts using a 12 mm ring enforced olytetrafluorethylene prosthesis. [39],[59]

The 5 years survival is better in patients treated surgically by shunt compared to those treated with sclerotherapy. [39]

Liver transplantation is considered as the only definitive treatment for cirrhosis in patients with variceal bleeding. [5],[60] Therefore, the initial techniques, used to control acute variceal bleed­ing should not make a future transplantation dif­ficult. Sclerotherapy, EVL and TIPSS are the methods of choice in transplant candidates. Fur­thermore, mesocaval and mesorenal shunts, which can be easily ligated during transplantation are also recommended. [60]

   Prophylaxis Top

Only one third of cirrhotic patients bleed from esophageal varices. When bleeding occurs it is associated with high rebleeding and mortality rates. Therefore various prophylactic measures have been evaluated.

Surgery: despite the fact that PSS is effective in prevention of bleeding it is a major surgery with complications and therefore unjustified for prophylaxis. [61],[62]

Sclerotherapy has been used as a prophylactic measure with controversial results. [5],[63],[64],[65],[66],[67] Meta­ analysis of nine studies revealed a superiority of sclerotherapy compared with control. However due to the heterogeneity of these studies, the result should be cautiously considered and sclerotherapy remain unjustified in patients who have not bled from esophageal varices. [35],[68]

B-adrenergic blockers: Non-selective B - adrenergic blockers effect on initial bleeding prophylaxis has been extensively studied and was found to reduce portal pressure in the majority of patients, [69],[70] however up to 50% of patients might fail to show this response [71] B-adrenergic blockers are found to significantly reduce the rate of bleeding, [72],[73] but their effect on survival is uncertain. [35] The efficacy of B-adrenergic bloc­kers is evaluated clinically by the reduction of heart rate. However, reduction of hepatic vein pressure gradient below 12 mm is considered as the best efficacy index of treatment. [72]

The variable non-responder rate, the non-com­pliance, the long duration, the adverse reactions and the cost of treatment limit the routine use of B-adrenergic blockers for the prophylaxis of bleeding from esophageal varices. However, it may be used in patients with large varices which represents a bleeding risk. [74]

   Conclusions Top

Several options are available to treat acute vari­ceal bleeding after resuscitating the patients. The selection of treatment modality should consider the simplicity, the efficacy and the safety of the method.

Immediate endoscopy after stabilizing the patients and sclerotherapy or variceal banding ligation is the first option. In case of failure to con­trol bleeding other procedures should be consi­dered according to the patients status. In unfit patients TIPSS, in stable patients a surgical proce­dures not interfering with liver hemodynamic are to be considered. In liver transplantation candi­date ES or EVL and in case of failure TIPSS, mesocaval or mesorenal shunt are recommended.

   References Top

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Correspondence Address:
Ibrahim A Al Mofleh
Department of Medicine, College of Medicine, King Saud University, P.O. Box 2925, Riyadh 11461
Saudi Arabia
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