Bleeding Esophageal Varices

The following is for informational purposes only.  The best place for medical care and questions are with your doctor.

If a child

  • Vomits blood
  • Vomits brown or black material which resembles coffee grounds
  • Or has black, tarry or bloody stools

This is a potentially life-threatening event, due to GI bleeding and low blood volume.

IMPORTANT INITIAL MANAGEMENT:

Go to the nearest Emergency Room in your area or call 911. (If you are waiting for an ambulance to arrive, lie flat and elevate legs.)

INITIAL MANAGEMENT AT THE HOSPITAL WOULD LIKELY INCLUDE:

• A large IV placed with the following studies drawn: o CBC with differential

• Reticulocyte count

• PT/PTT

• Type and cross for 2 units PRBC minimum

• Insert a nasogastric tube into the stomach, lavage with room temperature normal saline to verify the presence of blood. Tube left in place.

THERAPEUTIC OPTIONS: 

• H2-blockers, protein pump inhibitors

• Admission to an ICU

• Systemic octreotide or vasopressin

• Esophageal ligation (banding)

• Esophageal variceal sclerotherapy

• Sengstaken-Blakemore Tube

• Emergency radiology TIPS shunt

• Laser Coagulation, Heater Probe, and Bicap

• Emergency Surgical shunt

MEDICAL THERAPY FOR ESOPHAGEAL VARICES:

Pitressin (vasopressin):

• Given as a continuous infusion in ICU or on transport

• Enhances systemic pressure with peripheral vasoconstriction

• Causes inappropriate ADH, hyponatremia, seizures

• An alternative is octreotide

• Nitrates

SCLEROTHERAPY:

(Injection of varices with a sclerosing agent)

Indications and uses:

• Active variceal bleeding

• Therapy following a bleed

• Prophylactic therapy

• Role in pretransplant therapy

Alternative to this therapy:

• Esophageal variceal ligation (banding)

• Medical therapy with beta blockers

• Surgical shunt therapy

• Expectant clinical care with no therapy

ESOPHAGEAL BANDING:

(Acute or chronic care of esophageal varices)

Technique:

• Upper endoscopy

• Suction to pull varix into chamber

• Manual firing of a band over the neck of the varix

• Spring loaded multiple rubber bands

• Band occludes varices

Advantages:

• Necroses and falls off after several days

• Minimizes or eliminates many of the risks of sclerotherapy

EMERGENCY TIPS:

(Transvenous (jugular) Intrahepatic Portosystemic Shunt performed by interventional Radiologists – making a connection between the high pressure portal vein and the low pressure hepatic vein.)

Technique:

• Access the hepatic veins

• Perforate through to the portal veins

• Dilate the channel

• Place a stent and then dilate the stent

Advantages:

• Can be preformed emergently without surgery

• Does not require surgery of prehepatic vessels

Disadvantages:

• Common restenoses

PORTOSYSTEMIC SHUNTS:

(Reserved for repeated hemorrhages, significant pancytopenia secondary to hypersplenism and failure of sclerotherapy or banding.)

Technique:

• Portocaval shunt

• H-type mesocaval shunt

• Distal or proximal splenorenal shunt

• High likelihood of long-term success

Disadvantages:

• Major surgery

• Rearranges prehepatic vessels pre-transplant

• May clot with time

• Difficult or impossible in small infants

• Post-shunt encephalopathy may occur

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