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 NICE CG141.

• Initial Assessment and Resuscitation:
  • Perform a Blatchford score at first assessment NICE CG141.
  • Transfuse patients with massive bleeding according to local protocols, basing decisions on the full clinical picture to avoid over- or under-transfusion NICE CG141.
  • Offer platelet transfusion if the patient is actively bleeding and has a platelet count less than 50 x 109/litre NICE CG141. Do not offer if they are not actively bleeding and are haemodynamically stable NICE CG141.
  • 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 NICE CG141. If fibrinogen remains less than 1.5 g/litre despite FFP, offer cryoprecipitate NICE CG141.
  • For patients on warfarin who are actively bleeding, offer prothrombin complex concentrate NICE CG141.
• Specific Medical Management for Variceal Bleeding:
  • Terlipressin: Offer terlipressin to patients with suspected variceal bleeding at presentation NICE CG141. Treatment should stop after definitive haemostasis or after 5 days, unless there is another indication NICE CG141. 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 NICE CG141. Terlipressin is a key vasoconstrictor used in the initial management of variceal hemorrhage Edelson et al. 2021Pallio et al. 2023.
  • Prophylactic Antibiotics: Offer prophylactic antibiotic therapy at presentation to patients with suspected or confirmed variceal bleeding NICE CG141. This is also recommended for people with cirrhosis who have upper gastrointestinal bleeding NICE NG50. Prophylactic antibiotics are crucial to prevent infection in these patients Edelson et al. 2021Pallio et al. 2023.
• Endoscopy and Definitive Treatment:
  • Timing of Endoscopy: Offer endoscopy immediately after resuscitation for unstable patients with severe acute upper gastrointestinal bleeding NICE CG141. For all other patients, offer endoscopy within 24 hours of admission NICE CG141. Early endoscopy is vital for diagnosis and treatment Shung & Laine 2024.
  • Endoscopic Treatment for Oesophageal Varices: Use band ligation for bleeding from oesophageal varices NICE CG141. Endoscopic variceal ligation (EVL) is the preferred endoscopic method Edelson et al. 2021Pallio et al. 2023.
  • Endoscopic Treatment for Gastric Varices: Offer endoscopic injection of N-butyl-2-cyanoacrylate for bleeding from gastric varices NICE CG141.
  • Management of Refractory Bleeding: If bleeding from oesophageal varices is not controlled by band ligation, consider transjugular intrahepatic portosystemic shunts (TIPS) NICE CG141. TIPS may also be offered if bleeding from gastric varices is not controlled by endoscopic injection NICE CG141. TIPS is an option for uncontrolled variceal bleeding Edelson et al. 2021Pallio et al. 2023.
• Medication Review:
  • Stop other non-steroidal anti-inflammatory drugs (including COX-2 inhibitors) during the acute phase NICE CG141.
  • Continue low-dose aspirin for secondary prevention of vascular events once haemostasis has been achieved NICE CG141.
  • Discuss the risks and benefits of continuing clopidogrel (or other thienopyridine antiplatelet agents) with the appropriate specialist and the patient NICE CG141.
• 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 NICE CG141.