Variceal Bleeding FFH Med-2

8/12/2019 Variceal Bleeding FFH Med-2

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Varicose veins that develop in the esophagous as a result of

elevated pressure in the venous system of the abdomen.

Upper G.I. Bleeding is a Medical Emergency associated with high mortality.

80-90% bleed from esophageal varices & not from other sources.

Overall mortality of first bleed is 50% mainly due to patientsdying before they reach hospital.

50-70% patients experience a re-bleeding episode during

hospitalisation.

At least, a third will re-bleed within 6 weeks of discharge fromhospital.

No more than third will survive beyond one year.

Introduction


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Esophageal Varices


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Varices in the distal esophagus as viewed through an endoscope

Esophageal Varices


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About 30% cirrhotic patients with demonstrable varices manifest

bleed.

Almost all bleeding episodes occur within 2 years of initialobservation.

Once bleeding occurs 40-50% cirrhotic patients die within 6months.

There is an 80% incidence of re-bleeding once patient bleedsfrom varices.

Mortality seen with every re-bleeding is about 60%.

Every re-bleeding even if treated successfully requires a lot ofhospital resources, especially blood.

Facts & Figures


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Causes of Portal Hypertension

Liver Cirrhosis (alcoholic, biliary, posthepatitis)

Non-cirrhotic portal fibrosis/ Portal

hypertension

Schistosomiasis

Budd-Chiari Syndrome


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1stDegree Varices

2ndDegree Varices

3rdDegree Varices

Predictors of Bleeding in EV

- Size

- Red Spots

- Child Pugh Score


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EMERGENCY MANAGEMENT OF UPPER G.I. BLEEDING

AT FAMILY PHYSICIANS CLINIC

MINOR BLEEDING

(BP Stable, Pulse < 100/min)

History of past bleeding attacks,

jaundice/NSAIDs, other

medications

Inject Octreotide 50 mcg* i.v. stat

at the site of visit

No further bleeding

Patient remains stable

Consult G.I. Specialist/Hospital for

further evaluation & Endoscopy

MAJOR BLEEDING

Hypotensive Shock, Patient Collapse

Maintain i.v. line with

Normal Saline & Plasma

Expanders

Inject Octreotide 50 mcg stat i.v.AND START

I.V. infusion of Sandostatin

25 mcg/hour

HOW?

(Add 3 ampoules of 100 mcg

Sandostatin in 500 c.c.

dextrose/water 5% in 12 hours)

URGENTLY SHIFT PATIENT

TO HOSPITAL

* Sandostatin (Octreotide) is available as (a) 0.05 mg injection (50 mcg ampoule) (b) 0.1 mg injection (100 mcg ampoules)

For further Specialized Management please refer a Gastroenterologist

Note:

Upper G.I. Bleeding may present with

Vomiting of fresh blood

Black color loose stools


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Prevention

- Beta blockers and nitrates

Acute variceal bleeding

- Vasopressin

- Vasopressin Analogue

- Somatostatin

- Somatostatin Analogue


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Acts by decreasing portal pressure by

constricting splanchnic blood vessels

LIMITATIONS

- Short half life

- Systemic vasoconstriction

- MI and mesenteric Ischaemia


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Same mode of action as vasopressin

Longer half life

Fewer side effects

LIMITATIONS

- Less effective in controlling active bleeding andpreventing re-bleeding

- No reduction in transfusion requirements- Should be use with trans-dermal Nitroglycerineto counter cardiac side effects

(Hepatology 1993, vol.18, p 61-65)


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Contrindicated in IHD

(Management of Portal Hypertension and Budd Chiari Syndrome,

Andrew K Burroughs)

ECG and BP must be monitored

Can only be used when ICU facilities are

available

(Terlipressin package insert)


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Acts by selectively reducing hepatic blood flow

and wedge hepatic venous pressure

LIMITATIONS

- Shorter half life

- Necessitates continuous IV infusion

- Rebound bleeding


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Same pharmacologic effects as Somatostatin

Much longer half life

Significantly reduces intra-variceal pressure

Decreases the inflow of blood to the portalsystem

Increased selectivity

Potency greater than that of Somatostatin


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Advantages of Sandostatin (Octreotide)

Longer plasma half-life

(about 1-2 hours)

Longer duration of action

S.C. injection which can be

self-administered by the patient

More potent

More selective


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USES AND BENEFITS

Sandostatinis effective in control of acute variceal bleeding

at 24 hours and stops variceal haemorrhage in 80% of

patients.

Sandostatinis equally effective as endoscopic therapy in

mild, moderate and severe disease.

Sclerotherapy is not available at all centres and depends

upon the technical expertise.

Sandostatinwhen used prior to sclerotherapy produces an

effective Holding & prevents re-bleeding during the first 4

hours especially when used with sclerotherapy.


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Sandostatinis more effective than other modalities in theemergent control of active variceal bleeding.

Sandostatinreduces the transfusion requirements as

compared to other pharmacological treatment modalities i.e

1 unit versus 3 units within 48 hours.

Sandostatinhas an excellent safety profile than other

treatments. It is well tolerated & has fewer side effects.

Due to absence of systemic circulatory effects Sandostatin

can be used without special monitoring.

USES AND BENEFITS


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A recent meta-analysis evaluated 13 randomized trials ofoctreotide v/s several alternative interventions for varicealhemorrhage[21] These 13 trials included a total of 1077 patients(numbers ranged from 40 to 199 total patients per trial). Theendpoints analyzed involved assessments made at the end of therecorded follow-up, rather than at arbitrary times during the firstfew hours of hospitalization. The primary endpoints were:

Total rebleeding

Mortality

Complications

This study defined lack of control of bleeding as any episode of

rebleeding during the follow-up period It defined major complications as hypertension or hypotension,

cardiac or intestinal ischemia, arrhythmias, pneumonia, pulmonaryedema, or any side effect that required termination of treatment

Corley DA, Cello JP, Adkisson W, et al. Octreotide for acute esophageal variceal

bleeding: a meta-analysis. Gastroenterology. 2001;120:946-954.


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Meta-analysis demonstrated that most studies favor octreotide vs alternative

therapy (vasopressin/terlipressin, placebo/no therapy, and sclerotherapy) for

the control of bleeding in acute variceal hemorrhage


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0

10

20

30

40

50

60

70

80

90

100

Octreotide

Vaso/Terli

Sclero/Band

Placebo

Balloon

Major

Any


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Octreotide was associated with fewer Major Complicationthan vasopressin/ Terlipressin

A trend towards Morality benefitespecially against

Balloon or Vasopressin Comparable in efficacyto Emergency Sclerotherapy and

comparable or better than other modalities. Mostcommon dosage regime in studies was 2550 g IV for48- 120 hours

Addition of Octreotideto Sclerotherapy producedsignificant better initial bleeding control and Rebleedingrates and small survival advantage compared withvasopressin/Terlipressin

(Gastroenterology 2001, 120, p 946-954)


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50 mcg intravenous as bolus in case of acute bleeding

Maintain i.v. line and start

50 mcg per hour for 5 days by continous i.v. infusion

Emergency therapy required at Family Physicians Clinic

for a patient with projectile bloody vomiting reports


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Conclusion

At present, available clinical evidence suggests that, because of

its efficacy & lack of major side effects Sandostatin most closely

fulfil the requirements of the ideal vasoactive drugfor the

control of acute variceal bleeding.

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Variceal Bleeding FFH Med-2