Acute variceal bleeding.

Area of Science:

• Hepatology
• Gastroenterology
• Interventional Radiology

Background:

• Gastroesophageal varices are a common and serious complication of cirrhosis.
• Variceal bleeding mortality has decreased but remains significant (15-20%).
• Effective management requires a multi-modal approach including medical and endoscopic therapies.

Purpose of the Study:

• To review current best practices for managing acute gastroesophageal variceal bleeding.
• To highlight the role of early intervention and rescue therapies.
• To emphasize the benefit of early transjugular intrahepatic portosystemic shunt (TIPS) in high-risk patients.

Main Methods:

• Review of current treatment guidelines and recent clinical trials.
• Discussion of initial medical management: fluid resuscitation, blood transfusion, prophylactic antibiotics, and vasoactive drugs (terlipressin, somatostatin, octreotide).
• Emphasis on timely endoscopic therapy (band ligation or sclerotherapy) and rescue strategies including TIPS and balloon tamponade.

Main Results:

• Vasoactive therapy and prophylactic antibiotics improve outcomes.
• Variceal band ligation is the preferred endoscopic treatment.
• Transjugular intrahepatic portosystemic shunt (TIPS) with covered stents is the primary rescue therapy for refractory or severe rebleeding.
• Early TIPS placement (within 72 hours) in high-risk patients (Child B with active bleeding or Child C < 14) significantly reduces rebleeding and improves survival.

Conclusions:

• Standard care involves prompt medical, endoscopic, and potentially interventional treatments.
• Early identification of high-risk patients is critical for optimizing outcomes.
• Proactive use of TIPS in selected high-risk patients represents a significant advancement in managing severe variceal bleeding.