General and specific management

The endoscopist should be prepared to institute direct and indirect forms of therapy once the diagnosis of bleeding varices is made. Indirect methods consist of the use of vasopressin, octreotide, or propranolol to reduce pressure in the portal system. Vasopressin reduces portal flow by causing intense arterial spasm, and is best administered intravenously at the rate of 0.2 to 0.6 IU/min, with the smaller dosages being reserved for use in elderly patients whose course may be complicated by the onset of angina pectoris. The addition of nitroglycerin (glyceryl trinitrate) to the vasopressin seems to reduce the onset of complications while not reducing the benefits of this therapy.

Octreotide, a longer-lasting analog of somatostatin, has been found to inhibit portal blood flow, and may be more effective than vasopressin in stopping variceal hemorrhage without the danger of that drug's complications (GpfL19.9.3). An initial dose of 250 pg intravenously is recommended, followed by an infusion of 250 pg/h. The b-adrenergic blocking agent propranolol has also been used to decrease portal pressure and has been shown to reduce variceal bleeding at times. The goal of this treatment is to reduce the resting heart rate to about 60 beats/min.

Since variceal hemorrhage recurs frequently and the mortality increases with successive bleeding episodes, most therapeutic efforts today are directed towards elimination of varices by endoscopic, radiological, or surgical techniques. Although none of these approaches is perfect, there is no doubt that they have distinct advantages over previous approaches.

Tamponade of varices, using an intraesophageal balloon mounted on a medium-sized rubber tube, was often applied in the past when direct endoscopic measures aimed at obliterating varices were not available. The goal of this treatment was to compress varices in the esophagus and upper stomach until clots formed at the bleeding site(s). The balloons were deflated after 1 or 2 days, and the tube left in place for another day to make certain that bleeding did not immediately recur. It was clear that recurrence of hemorrhage was very frequent and that tamponade was not definitive treatment in any way. This procedure may still be useful for buying time for a heavily bleeding patient when immediate access to a well-equipped endoscopy suite is not available, when the use of vasopressin or somatostatin does not appear to be reducing the bleeding, and when hepatic encephalopathy, worsening renal function, and progressive hepatic failure are imminent.

The triple-lumen Sengstaken-Blakemore tube is passed through the nose, and its position checked by fluoroscopy to see that the free distal tip of the tube is pointing towards the pylorus, that the gastric 'anchoring' balloon is located in the cardia, and that the esophageal balloon is properly distended. Traction is then applied to the external, or upper, end of the tube assembly, making sure that the tube is padded with soft plastic foam where the side presses against the nostril. In some centers, the esophageal balloon is not distended in the belief that pressure in esophageal varices is adequately reduced by compression of the more proximal gastric veins. Others feel that heavier intragastric traction is necessary if the esophagus is not compressed, and there is danger of causing greater pain and gastric and nasal damage by this approach. The middle open lumen of the tube is aspirated frequently to determine whether bleeding has been arrested. Some physicians recommend placing a second tube in the esophagus above the esophageal balloon to prevent aspiration of mucus and blood. Patients with a tamponade assembly in place must be under constant care because of the danger of aspiration and the frequent need for sedation.

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