Bleeding Esophageal Varices and Fundic Varices Medications and Tubes

Bleeding From Esophageal Varices

Fig. 4.10 Bleeding esophageal varices

Fig. 4.10 Bleeding esophageal

The mortality rate due to variceal bleeding (Fig. 4.10) is high, at 15-30%. The recurrence rate after an initial bleed is approximately 60% during the first two weeks. One third of varices will stop bleeding spontaneously.

■ Treatment Methods

The following treatment methods are used:

► Pharmacological

- Terlipressin plus nitrate

► Balloon tamponade

- Sengstaken-Blakemore tube (for esophageal varices)

- Linton-Nachlas tube (for fundic varices)

► Endoscopic

- Sclerotherapy

- Banding

► Operative treatment

Besides the control of bleeding and prevention of rebleeding, additional therapeutic measures may be taken depending on the clinical situation (Table 4.8).

Table 4.8 Additional measures for variceal bleeding

► Antibiotic therapy (lowers risk of rebleeding and of spontaneous bacterial peritonitis)

► Lactulose 3x50 mL

► Protein restriction

► Fresh frozen plasma

► Packed red blood cells

► Volume replacement varices

Pharmacological Therapy of Bleeding Esophageal Varices

Principle and Key Characteristics

Principle: medication to lower the portal venous and intravenous pressure

Vasopressin and terlipressin are the only two medications that have been approved for the treatment of bleeding esophageal varices.

- Terlipressin is superior to vasopressin owing to its longer half-life.

- Terlipressin should be combined with nitrates due to possible side effects (ischemia and necrosis).

Pharmacologic therapy is an acceptable alternative to balloon tamponade if emergency endoscopy cannot be performed.

Materials

Terlipressin Glyceryl nitrate Intravenous access Perfusor and perfusor tubing Syringes

Technique

► Repeat at 1 mg every four to six hours

► Duration: two to three days

► Always combined with glyceryl nitrate i. v. by perfusor, 14 mg/hour

■ Balloon Tamponade

Principle and Key Characteristics

► Principle: external compression of the bleeding varix with an inflated balloon

► Suitable if emergency endoscopy is not an option or as a temporizing measure after unsuccessful endoscopic or operative treatment or TIPS

► Esophageal varices: Sengstaken-Blakemore tube (two balloons)

► Fundic varices: Linton-Nachlas tube (one balloon)

Problems

► Pressure necrosis

► Aspiration pneumonia

► Rupture of the cardia

► Retching or vomiting may dislodge the tube, causing airway obstruction (Tube can be cut in an emergency; keep scissors handy)

Materials

Sengstaken-Blakemore or Linton-Nachlas tube Topical anesthetic Lubricant Padding Adhesive tape Manometer 50-mL syringe Clamps

Technique

Do not tamponade if the patient is vomiting. Check the tube for air tightness before use. Smear the tube and balloon with lubricant. Anesthetize the nasal mucosa. Squeeze residual air from the balloon. Insert the tube transnasally, advancing to 50 cm. Sengstaken-Blakemore tube

- Inflate the gastric balloon to 150 mL and clamp off. Slowly withdraw the tube until a springy resistance, synchronous with respirations, is felt.

- Secure the tube with strong adhesive tape.

- Pad the tube at the nostrils.

- Inflate the epithelial balloon to 45 mmHg by manometry, then clamp.

► Linton-Nachlas tube

- Inflate the balloon to 400 mL.

- Withdraw until a springy resistance is felt.

- Secure in place.

- Add another 200 mL.

► Deflate the tube for 30 minutes every six to eight hours.

► Maximum duration of tube placement: 24 hours.

Endoscopic Treatments

The treatment of choice for bleeding varices is endoscopic therapy. The following methods are available:

► Sclerotherapy with polidocanol (esophageal varices)

► Rubber band ligation (esophageal varices)

► Sclerotherapy with Histoacryl (fundic varices)

Materials

► Sclerotherapy needle, 4-6 mm long

Sclerotherapy with Polidocanol (Ethoxysclerol)

Principle and Key Characteristics (Fig. 4.11 )

Principle: compression and thrombosis of the varix, induc tion of inflammation with subsequent scarring

Paravariceal or intravariceal injection

Established therapy

Advantages

- Good in cases where vision is poor

- Relatively easy to perform

Fig. 4.11 Treatment of esophageal varices. Principle of paravariceal and intravariceal injection of the sclerosant

► Lateral position with the upper body elevated

► No pharyngeal anesthesia

► Pulse oximetry

► The instrument is inserted, and the bleeding varix is identified.

► Injection is begun close to the cardia.

► Intravariceal and paravariceal injection

- 0.5 mL injected on both sides of the varix (produces compression, inflammation, fibrosis)

- 1.0 mL injected directly into the varix (induces thrombosis)

- Maximum of 2 mL per injection site

► If there is postinjection bleeding, advance the endoscope and compress the varix for approximately one minute.

► If no further bleeding occurs, sclerose any varices that show signs of an increased bleeding risk.

► If treatment is unsuccessful, discontinue sclerotherapy and insert a Sengstaken-Blakemore tube.

Aftercare

► See Management of Bleeding Varices, page 88.

Complications

► Sclerotherapy ulcer

► Esophageal stricture

► Esophageal perforation

► Pleural effusion

Fig. 4.11 Treatment of esophageal varices. Principle of paravariceal and intravariceal injection of the sclerosant

Ulcers Post Esophageal Varices Banding

Principle and Key Characteristics

► Varix is sucked into a sleeve at the endoscope tip and ligated with an elastic band.

► Induction of thrombosis, necrosis, and scarring

► Established therapy

► Advantages

- Low complication rate

- Overall mortality and mortality due to bleeding are lower than in sclerotherapy

- Early rebleeding is less common than with sclerotherapy

► Disadvantage

- Limited vision in cases with massive bleeding

Materials (Fig. 4.14a)

► Variceal ligation set (multi- or single-band ligator)

Entrap the varix, suck the varix into the sleeve, and release the elastic band.

Usually three or four bands are applied per sitting, but considerably more may be placed if needed. If bleeding is severe and it is difficult to identify the source, band the distal varices.

Aftercare

Repeat three or four times at two-week intervals. Reexamine at three months.

Complications

Early: perforation of the hypopharynx or esophagus by the overtube

Late: strictures, stenoses

► Use a standard endoscope with an overtube.

► Advance the overtube.

► Perform a complete EGD.

► Withdraw the endoscope.

► Set up the endoscopic and ligation set.

► Reenter through the overtube.

► Begin the ligation near the cardia.

Esophageal Ligation

Fig. 4.14 Banding of esophageal varices a Endoscope prepared for banding, with a close-up view of the endoscope tip

Fig. 4.14 Banding of esophageal varices a Endoscope prepared for banding, with a close-up view of the endoscope tip

Esophageal Banding Varices

Fig. 4.15 Banding of esophageal varices a The varix is identified b The endoscope is advanced

Fig. 4.15 Banding of esophageal varices a The varix is identified

The tip of the sleeve is placed over the varix

b The endoscope is advanced

Esophageal Varices Banding

The tip of the sleeve is placed over the varix

The varix is sucked into the sleeve d c

The varix is sucked into the sleeve

Esophageal Varices

b Banded esophageal varix

Varices Banding

e The elastic band is released f Appearance of the banded b Banded esophageal varix e The elastic band is released f Appearance of the banded

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