Refractory Variceal Bleeding: Approach To Management (Mini Review)

Short Review Acute variceal bleeding (AVB) is seen in 50-70% of patients with cirrhosis & portal hypertension (PHT) [1]. Over the time the severity of the bleeding and complications related to bleeding have significantly reduced due to improvement in clinical management, better availability of vasopressor drugs, improved endoscopic therapies as well as due to availability of definitive treatment options such as TIPS and liver transplantation. About 10-20% patients do not respond to initial management (failure to control bleeding within 48 hrs) and develop re bleeding within 5 days of starting the therapy (initial control of bleeding), these patients can be defined to have refractory variceal bleeding. The causes for refractory variceal bleeding are a. severe liver disease (high MELD-Na and CTP score) b. coagulopathy (increased PT, INR and low platelets) c. post EVL band ulcers (PEBU’s) or slippage of bands [2-4]. Failure to control bleeding leads to poorer outcome due to a. worsening liver failure b. development of organ dysfunction due to hypovolemia and progressive shock c. systemic sepsis and increased gut translocation of bacteria. The management in this group of patients depends upon the general condition of the patient and the liver disease status. There was a recent study which showed that endoscopic appearance of the varices after banding can determine the outcomes in addition to MELDNa score [4]. I. Generalized treatment for stabilization of the patient: a. This includes blood transfusion (packed red blood cell) to maintain a hemoglobin level of 7-8 gram / dl. The restrictive vs liberal treatment has shown that the restrictive strategy was better in terms of rebleeding and mortality [5]. b. The patients with coagulopathy can be treated either with blood products based on lab parameters (INR, platelet count, aPTT) or blood products based on TEG (thromboelastography). The conventional approach in coagulopathy with variceal bleeding is blood component based correction but the data does not support use of blood products in AVB. A recent RCT was done in cirrhotics with GI bleeding and cogulopathy, the patients had a non variceal bleeding source and were managed with TEG guided corrections in comparison to standard INR guided corrections. The study concluded that TEG based correction showed significant reduction in number of blood products