Endoscopy 2020; 52(07): 528-530
DOI: 10.1055/a-1185-1110
Editorial

Management of acute gastric variceal hemorrhage

Referring to Lo GH et al. p. 548–555
Mostafa Ibrahim
1   Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
2   Department of Gastroenterology and Hepatology, Theodor Bilharz Research Institute Cairo, Egypt
› Author Affiliations

Acute gastric variceal hemorrhage (AGHV) occurs in up to 20 % of patients with portal hypertension, and 65 % of those experience a bleeding episode within 2 years of diagnosis [1]. The management of AGVH involves a multidisciplinary approach including resuscitation, treatment of acute bleeding, secondary prophylaxis, and management of treatment failure.

“Management of AGVH necessitates a multidisciplinary effort and consists of initial resuscitation, treatment of acute bleeding, secondary prophylaxis, and management of treatment failure.”

With regard to initial management and resuscitation, in an acute bleeding episode the key goal is to achieve hemodynamic stability as soon as possible, through the administration of adequate fluids and blood transfusion to prevent early re-bleeding and deterioration of liver functions [2]. Patients with gastric variceal bleeding should be restrictively transfused to a hemoglobin level of only 7 – 8 g/dL to avoid exacerbation of bleeding by increasing portal pressure. In fact, hypovolemia and hypotension accelerate activation of endogenous vasoactive systems leading to splanchnic vasoconstriction and thus reducing portal blood pressure [2] [3].

Short-term antibiotic prophylaxis should be initiated in all patients with cirrhosis and variceal bleeding. In our daily practice we follow guidelines in administering either norfloxacin or intravenous ceftriaxone; however it is very important to tailor the antibiotics according to blood culture results [2] [3].

Pharmacologic therapy should be started in all patients with suspected AGVH. Vasoactive drugs that selectively constrict the mesenteric arterioles and decrease portal blood flow, are used as the initial treatment of AGVH prior to endoscopy. The duration of treatment with vasoactive agents after successful endoscopic hemostasis is not well defined. The usual recommendation is maintenance for 5 days [2] to prevent early re-bleeding episodes; however a randomized controlled trial demonstrated that the addition of somatostatin (vs. placebo) infusion for 5 days after successful endoscopic hemostasis did not reduce bleeding recurrence at 5 days, or mortality [4].

It is recommended that endoscopic treatment of AGVH should be done within 12 hours of admission. However, the performance of emergency endoscopic treatment is always challenging as it depends on the patient’s condition, conditions at the hospital, and the skills of the doctor [5].

Cyanoacrylate injection is the globally accepted primary intervention for bleeding gastric varices and is highly satisfactory in controlling bleeding [2]. It has proven to be more effective and safer than band ligation and sclerotherapy in this subset of patients, and has been considered to be the standard therapy. However, there has been much research into intravascular injection of a thrombus-forming material as an alternative to cyanoacrylate in the management of AGVH. Promising results have been demonstrated in small-scale studies, but this approach needs to be evaluated in larger trials before routine application.

In this issue of Endoscopy, Dr. Gin-Ho Lo and colleagues present their randomized study comparing thrombin and cyanoacrylate injection in the hemostasis of AVGH. The investigators aimed the study mainly at the complications of cyanoacrylate, namely post-injection ulcers, and assessed hemostasis as a secondary end point. The significant difference in rate of ulceration favored thrombin. In my opinion, the comparison of the two techniques from the point of view of complications is a very good initiative; however, more studies should be done in this area to assess cost – effectiveness and also differences in long-term outcomes [6].

It must be borne in mind that cyanoacrylate injection requires certain technical skills and the procedure can be further complicated by severe bleed and ulcerations. However, the optimal technique and dosage for the glue injection are still controversial [7].

Treatment failure occurs in 15 % – 20 % of patients with AGVH and is defined by the occurrence of any of the following during the acute bleeding episode (first 5 days): acute hematemesis or a combination of decreased blood pressure (systolic blood pressure under 80 mmHg), increased heart rate (more than 100 beats/minute), transfusion need (requirement of 4 units of blood or more), or hematocrit drop (more than 10 %).

For management of treatment failure, normally we should start by repeating endoscopy with injection of the bleeding varices, but this is not always easy. In the case of endoscopic failure, alternatives include balloon tamponade, transjugular intrahepatic portosystemic shunt (TIPS), and balloon-occluded retrograde transvenous obliteration (BRTO).

Balloon tamponade is used to achieve short-term hemostasis in patients with AGVH. It is associated with a high risk of re-bleeding following deflation of the balloon, hence, it should be only used as a temporary “bridge,” for a maximum of 24 h. Rescue TIPS is the rescue therapy of choice when endoscopic treatment has failed. Although there is clinical evidence that TIPS is the treatment of choice for selected patients after initial failure of endotherapy, its availability within the recommended time frame (48 h) remains a matter of concern in many places [8]. Finally, BRTO is an alternative interventional radiological technique that involves occluding blood flow by inflation of a balloon catheter within a draining vessel; this is followed by instillation of a sclerosant proximal to the site of balloon occlusion [8].

New modalities in the management of AVGH are emerging, namely the use of hemostatic powders and of endoscopic ultrasound (EUS)-guided variceal injection. Hemostatic powders, which were initially developed for management of nonvariceal bleeders, become cohesive and adhesive when they come into contact with moisture (blood or tissue) and form a stable barrier at the surface of the bleeding site, thus inducing hemostasis. Currently three hemostatic powders are available for endoscopic usage: hemostatic agent TC-325 (Hemospray), the EndoClot polysaccharide hemostatic system, and Ankaferd Bloodstopper. Hemospray has been reported to be useful in emergency management of AGVH as an addition to medical management before definitive endotherapy, with no major adverse events or device-related mortalities [9].

Injection of cyanoacrylate under EUS guidance enables precise delivery of glue into the varix lumen or perforating vessels and confirmation of vessel obliteration under doppler examination. Furthermore, under EUS guidance it is also possible to target the feeding vessel, rather than the varix lumen itself. An alternative approach to glue injection is the implantation of coils that are currently used for intravascular embolization treatments via an EUS fine-needle aspiration needle. The hybrid combination of coil and cyanoacrylate may offer the advantages of both techniques. However, the use of coils is limited because of the relative technical difficulty of deploying multiple coils especially in AGVH [10].

To summarize, management of AGVH necessitates a multidisciplinary effort and consists of initial resuscitation, treatment of acute bleeding, secondary prophylaxis, and management of treatment failure. Pharmacologic vasoconstriction should be started in all patients with AGVH and upper gastrointestinal endoscopy should be performed within 12 hours of presentation after hemodynamic stabilization.

To date, cyanoacrylate injection is the technique of choice to date for controlling gastric variceal bleeding; however, it carries many risks and complications. There are many promising new modalities, including the combination of coil and glue injection for management mainly of nonbleeding gastric varices, and the application of hemostatic powder, a technique that requires minimal expertise and could act as a bridge therapy.



Publication History

Article published online:
24 June 2020

© Georg Thieme Verlag KG
Stuttgart · New York

 
  • References

  • 1 Patch D, Dagher L. Acute variceal bleeding: general management. World J Gastroenterol 2001; 7: 466-475
  • 2 de Franchis R. Baveno VI Faculty. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol 2015; 63: 743-752
  • 3 Garcia-Pagan JC, Barrufet M, Cardenas A. et al. Management of gastric varices. Clin Gastroenterol Hepatol 2014; 12: 919-928.e1; quiz e51-52
  • 4 Azam Z, Hamid S, Jafri W. et al. Short course adjuvant terlipressin in acute variceal bleeding: A randomized double blind dummy controlled trial. J Hepatol 2012; 56: 819-824
  • 5 Hsu YC, Chung CS, Tseng CH. et al. Delayed endoscopy as a risk factor for in-hospital mortality in cirrhotic patients with acute variceal hemorrhage. J Gastroenterol Hepatol 2009; 24: 1294-1299
  • 6 Lo GH, Lin CW, Tai CM. et al. A prospective, randomized trial of thrombin versus cyanoacrylate injection in the control of acute gastric variceal hemorrhage. Endoscopy 2020; 52: 548-555
  • 7 Ibrahim M, Mostafa I, Deviere J. New developments in managing variceal bleeding. Gastroenterology 2018; 154: 1964-1969
  • 8 D’Amico M, Berzigotti A, Garcia-Pagan JC. Refractory acute variceal bleeding: what to do next?. Clin Liver Dis 2010; 14: 297-305
  • 9 Ibrahim M, El-Mikkawy A, Abdel HamidM. et al. Early application of haemostatic powder added to standard management for oesophagogastric variceal bleeding: A randomised trial. Gut 2019; Epub 2018 May 5 68: 844-853
  • 10 McCarty TR, Bazarbashi AN, Hathorn KE. et al. Combination therapy versus monotherapy for EUS-guided management of gastric varices: A systematic review and meta-analysis. Endosc Ultrasound 2020; 9: 6-15