Variceal haemorrhage

Overview Of Variceal haemorrhage

Variceal hemorrhage is a life-threatening complication of portal hypertension, most commonly associated with liver cirrhosis. It occurs when abnormally dilated veins (varices) in the esophagus or stomach rupture, leading to severe bleeding. Portal hypertension, often caused by chronic liver disease, increases pressure in the portal venous system, causing collateral vessels to form and dilate. These fragile varices are prone to rupture, resulting in massive gastrointestinal bleeding. Variceal hemorrhage is a medical emergency with high mortality rates if not treated promptly. Early recognition, resuscitation, and targeted interventions are critical to control bleeding and prevent recurrence. ---

Causes of Variceal haemorrhage

• The primary cause of variceal hemorrhage is portal hypertension, which can result from:
• Liver cirrhosis: Due to chronic hepatitis B or C, alcohol abuse, or non-alcoholic fatty liver disease (NAFLD).
• Portal vein thrombosis: Obstruction of the portal vein.
• Schistosomiasis: A parasitic infection causing liver fibrosis.
• Budd-Chiari syndrome: Hepatic vein obstruction.
• Idiopathic portal hypertension: Rare cases with no identifiable cause. Factors precipitating variceal rupture include: - Increased portal pressure. - Large variceal size. - Thin variceal walls. - Infections or inflammation. ---

Risk Factors of Variceal haemorrhage

• Risk factors for variceal hemorrhage include:
• Severe liver disease: Advanced cirrhosis with high Child-Pugh or MELD scores.
• Large varices: Identified on endoscopy.
• Red wale marks: Endoscopic signs of high rupture risk.
• Portal hypertension: Hepatic venous pressure gradient (HVPG) >12 mmHg.
• Alcohol abuse: Continued alcohol use in cirrhotic patients.
• Infection: Spontaneous bacterial peritonitis (SBP) or other infections.
• Non-compliance with treatment: Failure to take beta-blockers or attend follow-up. ---

Prevention of Variceal haemorrhage

• Preventive strategies include:
• Primary prophylaxis: - Non-selective beta-blockers for patients with high-risk varices. - Endoscopic band ligation for those intolerant to beta-blockers.
• Secondary prophylaxis: - Combination of beta-blockers and endoscopic therapy. - Regular endoscopic surveillance.
• Lifestyle modifications: - Abstinence from alcohol. - Weight loss and management of NAFLD.
• Vaccination: For hepatitis B and hepatitis A. ---

Prognosis of Variceal haemorrhage

• The prognosis depends on the severity of liver disease and the timeliness of treatment: - Mortality rates are high (15-20%) during the initial bleed. - Recurrent bleeding occurs in 60% of untreated patients within 1-2 years. - Early intervention and secondary prophylaxis improve survival. - Liver transplantation is the definitive treatment for eligible patients with advanced cirrhosis. ---

Complications of Variceal haemorrhage

• Complications of variceal hemorrhage include:
• Hypovolemic shock: Due to massive blood loss.
• Hepatic encephalopathy: Triggered by bleeding or infection.
• Acute kidney injury: Due to hypovolemia or hepatorenal syndrome.
• Infections: Spontaneous bacterial peritonitis or sepsis.
• Multiorgan failure: In severe cases. ---

Related Diseases of Variceal haemorrhage

• Variceal hemorrhage is associated with or can mimic other conditions, such as:
• Peptic ulcer disease: Another cause of upper gastrointestinal bleeding.
• Mallory-Weiss tear: A mucosal tear at the gastroesophageal junction.
• Gastric antral vascular ectasia (GAVE): A cause of chronic gastrointestinal bleeding.
• Portal hypertensive gastropathy: Diffuse gastric mucosal changes due to portal hypertension. Understanding variceal hemorrhage and its management is critical for improving outcomes in patients with liver disease.

Treatment of Variceal haemorrhage

Management of variceal hemorrhage involves resuscitation, bleeding control, and prevention of recurrence: 1. **Resuscitation**: - Secure airway if needed (risk of aspiration). - Administer IV fluids and blood products to restore hemodynamic stability. - Correct coagulopathy with vitamin K, fresh frozen plasma (FFP), or platelets. 2. **Control of bleeding**: - **Endoscopic therapy**: - Band ligation for esophageal varices. - Sclerotherapy or glue injection for gastric varices. - **Vasoactive drugs**: - Octreotide, terlipressin, or somatostatin to reduce portal pressure. - **Balloon tamponade**: Temporary measure with a Sengstaken-Blakemore tube for uncontrolled bleeding. - **Transjugular intrahepatic portosystemic shunt (TIPS)**: For refractory bleeding. 3. **Prevention of recurrence**: - Non-selective beta-blockers (e.g., propranolol, nadolol). - Repeat endoscopic band ligation. - TIPS or surgical shunts in selected cases. 4. **Management of complications**: - Antibiotics (e.g., ceftriaxone) to prevent infections. - Lactulose or rifaximin for hepatic encephalopathy. ---