pathophysiology

  • Results from portal hypertension with hepatic venous pressure gradient >10 mm Hg
  • Bleeding risk increases at portal pressures >12 mm Hg
  • Increased resistance diverts portal blood flow to systemic circulation
  • Dilated intraesophageal/gastric veins form
  • Rupture occurs when wall tension exceeds vessel strength

clinical presentation

acute stabilization

airway and access

  • Maintain airway, support breathing, ensure circulation
  • Intubate for severe encephalopathy or massive bleed
  • Secure two large-bore intravenous cannulas
  • Insert nasogastric tube to monitor bleeding, assess output, clear stomach

fluid and blood replacement

  • Resuscitate with crystalloids (normal saline)
  • Transfuse packed red blood cells
  • Target hemoglobin 7-9 g/dL
  • Avoid over-transfusion; prevents rebound portal pressure increase

coagulopathy correction

  • Administer intravenous vitamin K
  • Transfuse fresh frozen plasma, platelets, or cryoprecipitate (if fibrinogen <1 g/L)

pharmacologic therapy

vasoactive agents

  • Initiate rapidly, preferably before endoscopy
  • Octreotide (somatostatin analogue): Initial intravenous bolus 1 $\mu g/kg$, followed by continuous infusion 1.0-5.0 $\mu g/kg/hr$. Decreases splanchnic blood flow
  • Vasopressin: Potent splanchnic vasoconstrictor. Initial bolus 0.33 units/kg, then continuous infusion. Higher adverse effect profile (ischemia, hypertension)
  • Terlipressin: Prodrug of vasopressin, administered 8-20 $\mu g/kg$ every 4-8 hours

adjunctive medications

  • Administer intravenous proton pump inhibitors (e.g., pantoprazole) to prevent stress erosions and reduce acid injury
  • Initiate broad-spectrum antibiotics (e.g., third-generation cephalosporins for 7 days) to prevent secondary bacterial infections

endoscopic management

therapeutic modalities

  • Perform within 12 hours of presentation after hemodynamic stabilization
  • Endoscopic variceal ligation (EVL): Preferred method. Uses multiple band ligator to strangulate varix. Lower complication rate
  • Endoscopic sclerotherapy (EST): Inject sclerosants (1% ethoxysclerol, ethanolamine) intra/paravariceal. Alternative for children <2 years where banding device is too large
  • Gastric varices: Inject tissue adhesive glue (N-butyl-2-cyanoacrylate)

refractory bleeding management

mechanical tamponade

  • Sengstaken-Blakemore or Minnesota tube
  • Mechanical compression of varices
  • Temporizing measure (<12 hours)
  • Risk of aspiration, necrosis, perforation

interventional and surgical options

  • Transjugular intrahepatic portosystemic shunt (TIPS): Interventional radiology procedure. Metallic stent connects portal and hepatic vein. Reduces portal pressure. Used as bridge to transplant
  • Surgical shunts: Distal splenorenal shunt, meso-caval shunt, or Meso-Rex bypass. Indicated for preserved synthetic liver function
  • Liver transplantation: Definitive treatment for underlying end-stage liver disease or fulminant failure