Education And Debate

Fortnightly Review: Management of variceal haemorrhage

BMJ 1994; 308 doi: (Published 07 May 1994) Cite this as: BMJ 1994;308:1213
  1. S G J Wiliams,
  2. D Westaby
  1. Department of Gastroenterology, Chelsea and Westminster Hospital, London SW10 9NH Charing Cross Hospitals
  1. Correspondence and requests for reprints to: Dr Heitmann.
  • Accepted 29 November 1993

Variceal haemorrhage complicates the clinical course of chronic liver disease in about 30% of patients.1Mortality for the index bleed is as high as 50%,2with a 30% mortality for subsequent recurrent bleeds. The rate of recurrent haemorrhage in those who survive the initial bleeding episode is as high as 100% over two years.

Management of active variceal haemorrhage

The initial resuscitation of the patient is of paramount importance, with protection of the airway, particularly in patients with encephalopathy, and restoration of the circulating volume (box 1).

Box 1 - Initial resuscitation

  • Protect airway

  • Ensure adequate venous access

  • Consider central venous catheter

  • Consider Swan-Ganz catheter (in those with ascites or associated medical problem)

  • Transfuse (colloid, then cross matched whole blood)

Establishing adequate venous access, in some cases through a central venous catheter, is essential to ensure ease of fluid replacement and adequate monitoring of the patient. In patients with ascites, the elderly patients, and those with associated medical conditions such as ischaemic heart disease, the right atrial pressure may not accurately reflect left sided heart pressures so fluid replacement should be monitored with a Swan- Ganz catheter.

Detailed attention to fluid replacement is important for any gastrointestinal bleed and even more so in patients with established chronic liver disease. These patients may have reduced vascular tone and fail to mobilise pooled venous blood from the splanchnic circulation.3Failure to achieve prompt volume replacement may jeopardise renal and hepatic function, a major factor in the morbidity and mortality associated with a variceal bleed.3It is equally important to avoid overfilling as this may precipitate rebleeding, so the right atrial pressure should be maintained between 4 and 8 mm Hg.

Immediate transfusion of colloid (crystalloid in the form of saline should be avoided in patients with chronic liver disease because of impaired renal sodium excretion and the development …

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