Guidelines For Clinical Practice
Copyright ©2010 Baishideng. All rights reserved.
World J Hepatol. Jul 27, 2010; 2(7): 261-274
Published online Jul 27, 2010. doi: 10.4254/wjh.v2.i7.261
Acute esophageal variceal bleeding: Current strategies and new perspectives
Salvador Augustin, Antonio González, Joan Genescà
Salvador Augustin, Antonio González, Joan Genescà, Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d’Hebron, Institut de Recerca, Universitat Autònoma de Barcelona, Barcelona 08035, Spain
Author contributions: Augustin S, González A, and Genescàs A contributed equally to the design, writing and revision of this paper.
Correspondence to: Salvador Augustin, MD, Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Institut de Recerca, Passeig Vall d´Hebron 119-129, Barcelona 08035, Spain. saugustin@vhebron.net
Telephone: +34-93-2746140 Fax: +34-93-2746068
Received: February 18, 2010
Revised: June 14, 2010
Accepted: June 21, 2010
Published online: July 27, 2010
Abstract

Management of acute variceal bleeding has greatly improved over recent years. Available data indicates that general management of the bleeding cirrhotic patient by an experienced multidisciplinary team plays a major role in the final outcome of this complication. It is currently recommended to combine pharmacological and endoscopic therapies for the initial treatment of the acute bleeding. Vasoactive drugs (preferable somatostatin or terlipressin) should be started as soon as a variceal bleeding is suspected (ideally during transfer to hospital) and maintained afterwards for 2-5 d. After stabilizing the patient with cautious fluid and blood support, an emergency diagnostic endoscopy should be done and, as soon as a skilled endoscopist is available, an endoscopic variceal treatment (ligation as first choice, sclerotherapy if endoscopic variceal ligation not feasible) should be performed. Antibiotic prophylaxis must be regarded as an integral part of the treatment of acute variceal bleeding and should be started at admission and maintained for at least 7 d. In case of failure to control the acute bleeding, rescue therapies should be immediately started. Shunt therapies (especially transjugular intrahepatic portosystemic shunt) are very effective at controlling treatment failures after an acute variceal bleeding. Therapeutic developments and increasing knowledge in the prognosis of this complication may allow optimization of the management strategy by adapting the different treatments to the expected risk of complications for each patient in the near future. Theoretically, this approach would allow the initiation of early aggressive treatments in high-risk patients and spare low-risk individuals unnecessary procedures. Current research efforts will hopefully clarify this hypothesis and help to further improve the outcomes of the severe complication of cirrhosis.

Keywords: Portal hypertension; Variceal bleeding; Complications of cirrhosis