VARICEAL HAEMORRHAGE

VARICEAL HAEMORRHAGE
A. Volume resuscitation as in other causes of upper GIB
• maintain mean arterial pressure at 80mmHg
• avoid overtransfusion, aim for Hb of 8g/dl, haematocrit of 30%
• correct coagulopathy
B. NG tube can be inserted for emptying of blood in stomach but no suction should be applied to avoid rupturing varices
C. Investigations
• CBP, LFT, RFT
• PT, APTT & platelet
• Serology for HBV and HCV
• αFP
• Abdominal ultrasound
D. Vasoactive agents, to be given early and maintained for 2 –
5 days.
• Octreotide 50 μg iv bolus, then 50 μg/h iv infusion
• Somatostatin 250 μg iv bolus, then 250 μg/h iv infusion
• Terlipressin 1 – 2 mg IV bolus Q4 – 6H
• Vasopressin 0.4 units/min iv infusion
(Off label use, watch out for cardiovascular
complications)
E. IV thiamine for those with alcohol excess
F. Anti-encephalopathy regimen
• Correct fluid and electrolyte imbalances
• Lactulose 10-20 ml q4H-q8H to induce diarrhoea
• Low protein and low salt diet
Gastroenterology and Hepatology

G. Prevention of sepsis
• Short-term prophylactic antibiotic: PO norfloxacin 400mg bd , or PO/IV ciprofloxacin 400-500mg bd, or IV ceftriazone 1g/day or 5 – 7 days H. Control of bleeding
• Endoscopy: Endoscopic variceal ligation / sclerotherapy for oesophageal varices
Tissue glue like N-butyl-cyanoacrylate injection for fundal varices
• Consider balloon tamponade (for <24 hr) if: urgent endoscopy not available When vasoactive agent fails to control bleeding, or recurrent bleeding after endoscopy
• Consider TIPs or surgery.