Variceal haemorrhage

Introduction

Variceal haemorrhage is a life-threatening complication of portal hypertension, most commonly due to liver cirrhosis. It involves bleeding from dilated submucosal veins (varices), usually in the oesophagus or stomach. Prompt recognition and emergency management are essential to reduce morbidity and mortality.

Peak Incidence

• Most commonly affects individuals aged 40–60 years.
• Typically seen in patients with established liver disease.

Pathophysiology

• Portal hypertension leads to the formation of portosystemic collateral vessels, including varices.
• Increased pressure within these vessels causes them to dilate and become fragile, predisposing them to rupture and haemorrhage.

Symptoms

• Haematemesis – vomiting of fresh blood.
• Melaena – black, tarry stools due to digested blood.
• Haematochezia – bright red blood per rectum (in cases of massive upper GI bleeding).
• Dizziness or syncope due to hypovolaemia.

Signs

• Signs of chronic liver disease:
  • Jaundice.
  • Ascites.
  • Spider naevi.
  • Caput medusae.
  • Hepatosplenomegaly.
• Signs of portal hypertension:
  • Splenomegaly.
  • Dilated abdominal wall veins.
• Signs of hypovolaemic shock:
  • Cool, clammy skin.
  • Tachycardia.
  • Hypotension.
  • Reduced urine output.
• Altered mental status – may indicate hepatic encephalopathy.

Diagnosis

Endoscopy

• Oesophagogastroduodenoscopy (OGD) – Gold standard.
  • Enables direct visualisation, grading of varices, localisation of active bleeding, and immediate therapeutic intervention (e.g., banding or sclerotherapy).

Blood Tests

• FBC – May show:
  • Anaemia from blood loss.
  • Thrombocytopenia from splenic sequestration.
• LFTs – Elevated bilirubin, AST, ALT; low albumin (suggesting poor hepatic function).
• Coagulation profile – Prolonged PT/INR due to impaired liver synthesis.
• Urea & Electrolytes – Hyponatraemia is common in advanced liver disease.

Additional Studies

• Transient elastography (FibroScan) – Assesses liver fibrosis severity.
• Imaging – Not routinely required but may detect varices incidentally.

Scoring Systems

• Glasgow-Blatchford Score – Pre-endoscopy tool to assess need for intervention in upper GI bleeding.
• Rockall Score – Post-endoscopy score to predict risk of rebleeding and mortality.
• Child-Pugh Score – Assesses severity of underlying liver disease and prognosis.
• MELD Score – Estimates mortality risk in advanced liver disease; useful for transplant assessment.

Complications

• Rebleeding – Common within the first few weeks.
• Hepatic encephalopathy – Often precipitated by GI bleeding.
• Spontaneous bacterial peritonitis (SBP).
• Hypovolaemic shock.
• Death – Mortality can be as high as 20% within six weeks.

Management

Acute Bleeding Management

1. Resuscitation
   • ABCDE approach.
   • Two large-bore IV cannulas.
   • IV fluids and blood transfusion as needed.
   • Activate the Major Haemorrhage Protocol.
     • Transfuse to maintain Hb >70 g/L.
     • Correct coagulopathy with:
       • Vitamin K (if deficient).
       • Fresh Frozen Plasma (FFP).
       • Platelets if <50 × 10⁹/L.
2. Medical Therapy
   • Terlipressin – A vasopressin analogue that reduces portal pressure and bleeding.
   • Broad-spectrum antibiotics – Usually ceftriaxone or ciprofloxacin, to prevent SBP.
   • Reverse any anticoagulation if appropriate.
3. Endoscopic Therapy
   • Variceal Band Ligation (VBL) – First-line for oesophageal varices.
   • Sclerotherapy – May be used for gastric varices or when banding is not feasible.
4. Balloon Tamponade
   • Sengstaken-Blakemore Tube – A temporary measure for uncontrolled variceal bleeding while awaiting definitive therapy.
5. TIPS (Transjugular Intrahepatic Portosystemic Shunt)
   • Considered in refractory cases where bleeding persists despite medical and endoscopic therapy.

Secondary Prophylaxis (Prevention of Rebleeding)

• Non-selective beta-blockers (e.g., propranolol, nadolol) – Reduce portal pressure.
• Repeat endoscopy with VBL – Until varices are eradicated.

Additional Measures

• Thiamine supplementation – In patients with alcohol-related liver disease to prevent Wernicke’s encephalopathy.

Surveillance

• Cirrhotic patients:

  • Should undergo OGD at diagnosis.
  • If no varices: Repeat every 2–3 years.
  • If small varices: Repeat every 1–2 years or start prophylaxis.