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Bleeding varices: 1. Emergency management

S S Hanna, W D Warren, J T Galambos

    Canadian Medical Association Journal
    |January 1, 1981
    PubMed
    Summary
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    Emergency management of bleeding varices aims to stop hemorrhage nonoperatively. Endoscopic diagnosis categorizes patients for tailored treatment, prioritizing non-surgical interventions to reduce mortality risks associated with emergency shunt surgery.

    Area of Science:

    • Gastroenterology
    • Emergency Medicine
    • Interventional Radiology

    Background:

    • Bleeding varices pose a significant risk for upper gastrointestinal hemorrhage.
    • Emergency shunt surgery carries a higher mortality rate compared to elective procedures.

    Purpose of the Study:

    • To outline an emergency management strategy for bleeding varices.
    • To prioritize nonoperative hemostasis and avoid high-mortality emergency shunt surgery.

    Main Methods:

    • Immediate endoscopy to diagnose bleeding varices and stratify patients into spontaneous (Group 1), slow (Group 2), or rapid (Group 3) bleeding categories.
    • Pharmacological management with intravenous vasopressin, escalating to intra-arterial vasopressin or angiography if needed.
    • Endoscopic sclerotherapy, Sengstaken-Blakemore tube tamponade, or urgent shunt surgery based on patient risk and response to initial treatments.

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    Main Results:

    • Group 2 patients failing intravenous vasopressin proceed to angiography/intra-arterial vasopressin, with shunt surgery for low-risk and endoscopic sclerotherapy for high-risk patients.
    • Group 3 patients receive intravenous vasopressin, followed by tamponade for low-risk patients or intra-arterial treatment for high-risk patients if bleeding persists.
    • Salvage therapies for refractory bleeding include emergency mesocaval shunt or endoscopic/transhepatic sclerotherapy.

    Conclusions:

    • A stepwise, nonoperative approach to bleeding varices can effectively manage hemorrhage.
    • Stratifying patients based on bleeding severity and surgical risk allows for tailored, mortality-reducing interventions.
    • Endoscopic and radiological interventions offer alternatives to emergency surgery for high-risk patients.