How should I manage a patient with known oesophageal varices who presents with acute upper gastrointestinal bleeding?

When a patient with known oesophageal varices presents with acute upper gastrointestinal bleeding, immediate and urgent management is crucial, typically requiring hospital admission and specialist involvement ¹.

• Initial Assessment and Resuscitation:
  • Perform a Blatchford score at first assessment ¹.
  • Transfuse patients with massive bleeding according to local protocols, basing decisions on the full clinical picture to avoid over- or under-transfusion ¹.
  • Offer platelet transfusion if the patient is actively bleeding and has a platelet count less than 50 x 10⁹/litre ¹. Do not offer if they are not actively bleeding and are haemodynamically stable ¹.
  • Offer fresh frozen plasma (FFP) if actively bleeding and prothrombin time (or INR) or activated partial thromboplastin time is greater than 1.5 times normal ¹. If fibrinogen remains less than 1.5 g/litre despite FFP, offer cryoprecipitate ¹.
  • For patients on warfarin who are actively bleeding, offer prothrombin complex concentrate ¹.
• Specific Medical Management for Variceal Bleeding:
  • Terlipressin: Offer terlipressin to patients with suspected variceal bleeding at presentation ¹. Treatment should stop after definitive haemostasis or after 5 days, unless there is another indication ¹. It is important to note that at the time of the guideline's publication (June 2012), the maximum duration was 72 hours, and informed consent for off-label use should be obtained and documented ¹. Terlipressin is a key vasoconstrictor used in the initial management of variceal hemorrhage (Edelson et al., 2021; Pallio et al., 2023).
  • Prophylactic Antibiotics: Offer prophylactic antibiotic therapy at presentation to patients with suspected or confirmed variceal bleeding ¹. This is also recommended for people with cirrhosis who have upper gastrointestinal bleeding ². Prophylactic antibiotics are crucial to prevent infection in these patients (Edelson et al., 2021; Pallio et al., 2023).
• Endoscopy and Definitive Treatment:
  • Timing of Endoscopy: Offer endoscopy immediately after resuscitation for unstable patients with severe acute upper gastrointestinal bleeding ¹. For all other patients, offer endoscopy within 24 hours of admission ¹. Early endoscopy is vital for diagnosis and treatment (Shung and Laine, 2024).
  • Endoscopic Treatment for Oesophageal Varices: Use band ligation for bleeding from oesophageal varices ¹. Endoscopic variceal ligation (EVL) is the preferred endoscopic method (Edelson et al., 2021; Pallio et al., 2023).
  • Endoscopic Treatment for Gastric Varices: Offer endoscopic injection of N-butyl-2-cyanoacrylate for bleeding from gastric varices ¹.
  • Management of Refractory Bleeding: If bleeding from oesophageal varices is not controlled by band ligation, consider transjugular intrahepatic portosystemic shunts (TIPS) ¹. TIPS may also be offered if bleeding from gastric varices is not controlled by endoscopic injection ¹. TIPS is an option for uncontrolled variceal bleeding (Edelson et al., 2021; Pallio et al., 2023).
• Medication Review:
  • Stop other non-steroidal anti-inflammatory drugs (including COX-2 inhibitors) during the acute phase ¹.
  • Continue low-dose aspirin for secondary prevention of vascular events once haemostasis has been achieved ¹.
  • Discuss the risks and benefits of continuing clopidogrel (or other thienopyridine antiplatelet agents) with the appropriate specialist and the patient ¹.
• Information and Support:
  • Establish good communication with the patient and their family/carers, providing consistent verbal and written information throughout their hospital stay and following discharge ¹.