On the Bleeding Edge: Mastering GI Emergencies and Inpatient GI Consultation (On-Demand)

Pdf Summary

This document reviews current approaches to <strong>acute variceal hemorrhage</strong> management, focusing on both <strong>esophageal</strong> and <strong>gastric</strong> varices.

Key clinical reminders include that acute bleeding may be triggered by <strong>thrombosis, tumor, or alcohol</strong>, with <strong>6-week mortality of 15–20%</strong> and the <strong>highest rebleeding risk in the first 5 days</strong>. High-risk features for rebleeding include <strong>Child-Pugh C</strong>, <strong>active bleeding at endoscopy</strong>, <strong>portal pressure gradient ≥20 mmHg</strong>, and <strong>acute kidney injury</strong>. Before endoscopy, patients should receive <strong>vasoactive drugs immediately for 2–5 days</strong>, <strong>antibiotic prophylaxis</strong>, treatment of <strong>encephalopathy</strong>, <strong>transfusion to hemoglobin 7 g/dL</strong>, and <strong>airway protection when needed</strong>.

For <strong>esophageal varices</strong>, first-line endoscopic therapy is <strong>band ligation</strong>, applied carefully to the largest or most high-risk columns, starting at the gastroesophageal junction and avoiding circumferential banding. If bleeding persists, options include <strong>repeat endoscopy</strong>, <strong>sclerotherapy</strong>, <strong>tamponade</strong> with balloon devices, <strong>esophageal stenting</strong>, or <strong>TIPS</strong>, depending on availability and patient factors.

For <strong>gastric varices</strong>, management depends on varix type and portal/shunt anatomy. Treatment options include <strong>cyanoacrylate glue injection</strong>, <strong>EUS-guided coil embolization with or without glue</strong>, and <strong>interventional radiology therapies</strong>. The document highlights that EUS-guided therapy may reduce embolization risk and improve obliteration.

<strong>Hemostatic powders</strong> are not standard guideline therapy and are generally not recommended for variceal bleeding, though they may be used selectively in emergencies.

Finally, the presentation emphasizes the importance of having a <strong>prepared plan</strong>, keeping <strong>variceal kits</strong> available, using the <strong>first intervention as the best intervention</strong>, and involving <strong>advanced endoscopy and interventional radiology early</strong>.

Meta Tag

Concept Acute Variceal Hemorrhage

Concept Endoscopic Band Ligation

Concept TIPS

Concept Vasoactive Therapy

Concept Esophageal Varices

Keywords

acute variceal hemorrhage

esophageal varices

gastric varices

band ligation

cyanoacrylate glue

EUS-guided coil embolization

TIPS

vasoactive drugs

antibiotic prophylaxis

rebleeding risk

Acute Variceal Hemorrhage

Endoscopic Band Ligation

TIPS

Vasoactive Therapy

Esophageal Varices