clinical support for the notion that portal diversion accelerated the decline of liver function in patients

with cirrhosis and they are no longer performed for this indication.

Endoscopic Sclerotherapy and Variceal Ligation. In the past, prophylactic sclerotherapy to prevent

variceal bleeding was an accepted practice but technical challenges and esophageal and pulmonary

complications have led to abandonment of endoscopic sclerotherapy (ES) for the primary prevention of

variceal bleeding. Initial investigations of the effectiveness of endoscopic variceal ligation (EVL) as a

method of primary prophylaxis to prevent initial bleeding in high-risk patients with esophageal varices

reported mixed results.218,219 In one study, no statistically significant differences in the incidence of

initial bleeding and mortality were found in a comparison of patients after variceal ligation with

controls,220 though subgroup analysis revealed a significant decrease in the incidence of initial bleeding

for Child–Pugh class B patients.219 Furthermore, there seems to be a significant prognostic divergence

related to variceal size. As data have accumulated, consensus recommendations regarding prophylaxis

have emerged as presented in recent practice guidelines from the AASLD. Briefly summarized, patients

with cirrhosis with small, low-risk varices should be managed with beta-blocker prophylaxis. In those

with medium or large varices with high-risk features (Child B or C, red wale markings), either EVL or

beta blockade is acceptable primary prophylaxis. In the absence of the above high-risk features, beta

blockade is preferred, with EVL reserved for those patients who have contraindications to, or are

intolerant of beta blockers.198

Treatment of Esophageal Variceal Bleeding

Initial Management. Initial management of the patient with acute variceal bleeding includes the

following: (a) establishment and maintenance of an airway; (b) hemodynamic monitoring; (c)

placement of large-bore intravenous lines; (d) full laboratory investigation, including measurement of

hemoglobin and hematocrit, coagulation profile, liver function tests, measurement of electrolytes, and

assessment of renal function; (e) administration of blood products as needed, including packed red cells,

platelets, and fresh frozen plasma; and (f) intensive care unit monitoring. Hemoglobin concentration

should be maintained around 8 g/dL.221,222 Transfusion to higher hemoglobin concentrations has been

associated with higher portal pressure and worse outcomes. Furthermore, as gastrointestinal bleeding is

associated with a high risk of subsequent spontaneous bacterial peritonitis in patients with cirrhosis, a 7-

day course of antibiotics (typically a quinolone such as norfloxacin or ciprofloxacin) is also

recommended as standard therapy for acute variceal bleeding.223

Pharmacologic Therapy. The administration of vasoactive medications can be commenced almost

immediately after patient presentation if the history and physical findings suggest variceal bleeding.

This practice decreases the rate of bleeding and enhances the endoscopic ability to visualize the site(s)

of bleeding.

Vasopressin (antidiuretic hormone) has potent splanchnic vasoconstrictive properties that decrease

portal venous and collateral flow and reduce portal pressure. In randomized prospective trials, as well

as in a meta-analysis, continuous intravenous administration of vasopressin has proved to reduce

variceal bleeding, an observation initially made in 1962.224–226 When vasopressin was compared with

placebo, bleeding stopped in an average of 52% of patients who received vasopressin and 18% of

patients who received placebo. Rates of rebleeding as high as 45% were noted, however. Because of

coronary vasoconstrictive effects, vasopressin is often used in combination with a vasodilator, such as

nitroglycerin. The combination provides protection from adverse cardiac events and increases the

effectiveness of vasopressin by decreasing intrahepatic and collateral resistance.227 A meta-analysis of

three randomized controlled trials confirmed the increased effectiveness of vasopressin and

nitroglycerin in comparison with vasopressin alone.228

Somatostatin and octreotide, its longer-acting eight-amino acid derivative, have been used extensively

for the treatment of variceal bleeding. These agents decrease splanchnic blood flow indirectly by

reducing the levels of other factors, such as glucagon, vasoactive intestinal peptide, and substance P,

rather than by direct vasoconstriction.229 The effects of somatostatin are limited to the splanchnic

circulation, so that side effects are minimized.230 A somatostatin and octreotide combination has proved

to be as effective as vasopressin, sclerotherapy, and balloon tamponade in multiple studies.231–233

Because of the lack of complications related to somatostatin therapy, octreotide is the initial drug of

choice for the treatment of acute variceal hemorrhage. Dosing typically consists of a bolus of 50 μg

followed by an infusion of 50 μg/hr, to be initiated as soon as variceal bleeding is suspected and

continued for 3 to 5 days after the diagnosis has been verified.198

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Endoscopic Interventions. Esophageal variceal ligation has become the principal approach to the

initial control and ongoing treatment of variceal bleeding; it is performed at the bedside in acute

bleeding and has replaced variceal sclerosis.

The technique of ligation (Fig. 59-6) includes placing an endoscope over a sheath (which allows

multiple insertions and removal of the endoscope), suctioning of a varix into the lumen of a plastic

channel, and then placing a rubber band around the tissue. The procedure is similar to the ligation of

hemorrhoids. The tissue then sloughs in 1 to 3 days, leaving a shallow ulcer. Up to six bands can be

placed at each session. Newer endoscopes allow for the placement of multiple bands without removal of

the endoscope.

Success rates for variceal ligation range from 80% to 100%, in comparison with 77% to 94% for

sclerotherapy, in controlled trials.234 In patients with profuse bleeding, however, the type of endoscope

used for variceal ligation may make visualization of the bleeding varices difficult leading some

investigators to choose sclerotherapy in these patients, and use variceal ligation once bleeding is

somewhat controlled.

Balloon Tamponade. The vast majority of patients (75% to 90%) with bleeding esophageal varices

respond to endoscopic or pharmacologic therapy. For patients who fail these interventions, balloon

tamponade (Fig. 59-7) is an alternative therapy with a high success rate in controlling bleeding. It

entails the placement of a specialized nasogastric tube with two balloons that can be inflated separately

and to different pressures to apply direct compression to the gastroesophageal junction and the

esophagus. Once the mainstay in the initial management of variceal bleeding, use of these tubes is

becoming a lost art, most suitable for initial stabilization of patients in a facility with limited

availability of endoscopic or radiologic support. Because these tubes are difficult to use, and may cause

fatal complications with esophageal injury, it remains important for surgeons and gastroenterologists

with responsibility for managing gastrointestinal bleeding to understand principles for safe use. The

most commonly used tubes are the Sengstaken–Blakemore tube and the Minnesota tube. The former

consists of a gastric balloon and an esophageal balloon with a sump port for gastric suctioning. The

latter tube has an additional port above the esophageal balloon for the aspiration of saliva and other

material from the esophagus and pharynx.

Figure 59-6. Endoscopic ligation of esophageal varices. The device used for ligation is based on the standard Barron-type ligator

for the treatment of anal hemorrhoids. The esophageal varix is drawn up into the ligating device with suction (A), and the base of

the varix is ligated with an O-ring (B). Up to six varices can be treated at a single session.

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Figure 59-7. The Sengstaken–Blakemore tube is used to tamponade acutely bleeding gastroesophageal varices. The tube has three

lumina—one to aspirate the stomach, another to inflate the gastric balloon, and a third to inflate the esophageal balloon. Patients

treated with balloon tamponade should be in an intensive care unit, and endotracheal tubes should be placed in almost all to

prevent aspiration.

Placement of these tubes begins with the establishment of a safe airway by endotracheal intubation.

The tube is then passed through the nose and into the stomach. Radiographic confirmation that the tip

of the tube is in the stomach is required before balloon inflation to prevent inadvertent intraesophageal

inflation of the gastric balloon and resultant perforation. The gastric balloon is inflated with 200 mL of

air and firmly pulled backward against the gastroesophageal junction to tamponade any proximal

gastric bleeding. The esophageal balloon is then inflated to a pressure of 30 to 40 mm Hg, and the tube

is secured to the patient by means of a facemask or helmet to ensure adequate stability of the tube and

prevent inadvertent removal.

Because of the possible complications of balloon tamponade (e.g., aspiration, esophageal and gastric

perforations, necrosis), which occur in 10% to 20% of patients, its use is restricted to approximately 24

hours. Success rates for cessation of bleeding are 70% to 80%, but more than half of all patients rebleed

when the balloons are deflated. Although this method is highly effective in the initial control of

bleeding, with an efficacy similar to that of pharmacologic agents, because of its transient effects it can

be used only as a temporizing measure in anticipation of a more definitive procedure (e.g., TIPS,

placement of a surgical shunt, or transplantation) and is used only after endoscopic and pharmacologic

therapies have failed.

Transjugular Intrahepatic Portosystemic Shunt. In the 10% to 20% of patients who continue to

bleed or who have early rebleeding, a shunt procedure (to bypass the high-pressure hepatic vascular

bed) may be indicated (Algorithm 59-1). The mortality rate associated with failure to control bleeding

can be as high as 90%, and surgically created shunts in this setting are associated with a high morbidity

and mortality rate.

10 The TIPS (Fig. 59-8) has become first-line treatment for bleeding esophageal varices when the

aforementioned attempts fail.235 Absolute contraindications to TIPS include congestive heart failure,

uncontrolled sepsis, multiple hepatic cysts, severe pulmonary hypertension, and uncontrolled biliary

obstruction. Relative contraindications include HCC, hepatic vein obstruction, severe coagulopathy or

thrombocytopenia, and moderate pulmonary hypertension.236 After ultrasonographic confirmation of

patency of the portal vein, the procedure is performed in the interventional radiology suite, where a

wire-guided stent (8 to 12 mm in diameter) is placed percutaneously into the jugular vein. The wire is

then guided through the superior vena cava, right atrium, and inferior vena cava into a hepatic vein,

after which the catheter traverses the hepatic parenchyma and joins the hepatic vein to a portal vein.

This connection effectively creates a side-to-side portacaval shunt. Success rates in the cessation of

variceal bleeding are as high as 90% to 100%, with an incidence of recurrent bleeding of approximately

10%.237,238

As discussed earlier, the ideal portosystemic shunt lowers the pressure in the portal system without

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