Page 1473 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

1012 PART 9: Gastrointestinal Disorders

consideration in cirrhotic patients who have been previously on fluo- Terlipressin is a long-acting vasopressin analogue that has received
roquinolones for the prevention of spontaneous bacterial peritonitis a favorable recommendation based on European studies, which report
(SBP). It is recommended that intravenous antibiotics be started initially, fewer side effects than vasopressin and an efficacy similar to that of
followed by a switch to an oral formulation once the bleeding has been octreotide and endoscopic sclerotherapy. In addition, a systematic
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stabilized, for a total duration of 7 days. Prior to initiating antibiotic review comparing trials of terlipressin with other pharmacotherapies
therapy, blood, urine, and (if indicated) ascitic fluid cultures should be identified terlipressin as the only pharmacologic agent that reduced
obtained. mortality. More recently, the efficacy of terlipressin was shown to be
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similar to octreotide as an adjuvant therapy for the control of esophageal
Hematologic: In acute variceal bleeding, both under- and overtransfu- variceal bleed and in-hospital survival. Terlipressin alone is inferior
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sion should be avoided. Undertransfusion can lead to tissue hypoxia, to terlipressin combined with band ligation in the treatment of acute
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and overtransfusion can lead to rebound portal hypertension, and variceal bleeding without active bleeding at endoscopy. In conclu-
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possibly worsening of the acute bleeding episode. One randomized sion, endoscopic band ligation combined with a somatostatin analogue
prospective study showed that a restrictive strategy of blood transfusion (octreotide or terlipressin) remains the standard of care for acute vari-
with a hemoglobin threshold of 7 g/dL resulted in decreased transfusion ceal bleeding.
requirements, with a similar incidence of side effects and survival as
compared to a liberal strategy of blood transfusion with a hemoglobin ■ ENDOSCOPIC THERAPY
threshold of 9 g/dL. Failure to control bleeding was higher in the liberal
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strategy group. Another recent randomized prospective study showed Following the administration of pharmacotherapy, emergent endos-
that a restrictive transfusion strategy significantly improved outcomes copy with therapeutic hemostatic intent is imperative. As outlined in
in patients with acute upper gastrointestinal bleeding, and especially in Figure 105-1, endoscopic evaluation can localize the source of the
the subgroup of patients with Child-Pugh cirrhosis class A and B. In variceal bleed to an esophageal or gastric varix. This is an important
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general, a hemoglobin of 7 to 8 is safe except in patients with cardiac distinction because, while esophageal variceal bleeding is amenable to
ischemia. 36 endoscopic therapy, gastric variceal bleeding may require more aggres-
In addition, fresh frozen plasma should be given to correct coagu- sive salvage measures, as outlined below.
lopathy; however, this should not delay endoscopy. rFVIIa is used as a Endoscopic therapy is based on the interruption of blood flow
procoagulant that can rapidly correct severe coagulopathy associated through the venous collateral system lining the distal esophagus and
with decompensated liver disease. Initial studies suggested that it can gastric cardia using either stimulation of thrombosis (eg, sclerotherapy)
promote hemostasis in variceal hemorrhage. 23,24 However, two large or immediate occlusion (eg, band ligation). The two established forms of
subsequent trials of rFVIIa in cirrhotic patients with upper gastroin- endoscopic therapy are endoscopic sclerotherapy (EST) and endoscopic
testinal bleeding showed no benefit in controlling variceal hemorrhage, variceal band ligation (EVL). While sclerotherapy involves the intra-
rebleeding rates or mortality, 25,26 and therefore, this drug is currently not variceal or paravariceal injection of a sclerosant (eg, sodium morrhuate),
recommended in the setting of variceal bleeding. band ligation involves the placement of small bands around varices in
the distal 5 cm of the esophagus (Fig. 105-2). A meta-analysis has shown
Neurologic: In the setting of decompensated liver disease, variceal that EVL is superior to EST in initial hemostasis, obliteration of varices,
bleeding could induce or exacerbate hepatic encephalopathy (HE). rates of recurrent bleeding, complications, and mortality. EVL was also
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Therefore, in the presence of decreased mental status during variceal shown to be superior to sclerotherapy when both treatments are com-
bleeding, HE should be considered a potential etiology in addition to bined with a somatostatin analogue, and EVL is now the endoscopic
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cerebral hypoperfusion, and empirical lactulose therapy via an NG tube treatment of choice for acute variceal hemorrhage. However, a techni-
or as an enema should be considered. cal challenge during use of the band ligator apparatus is the decreased
endoscopic field of view in a setting already complicated by active
Hemostatic Therapy: Specific therapies aimed at arresting active bleed-
ing include pharmacotherapy and endoscopic therapy. Multiple studies hemorrhage. Therefore, EST may be indicated in the setting of poor
have proven the increased hemostatic efficacy of combined pharmaco- initial visualization, followed later by definitive EVL treatment.
therapy and endoscopic therapy over either treatment alone. Gastric Varices: While the preceding endoscopic interventions are
■ PHARMACOTHERAPY effective in esophageal variceal bleeding, gastric variceal bleeding
presents a technical challenge. Gastric varices are located deeper in
In the setting of variceal bleeding, pharmacologic agents are aimed the submucosa, where EVL and EST are not successful in obtaining
sustained hemostasis. Initial studies reporting successful hemosta-
at causing splanchnic vasoconstriction and reducing portal hyper- sis with intravariceal injection of cyanoacrylate tissue glue 44,45 and
tension. Empiric pharmacotherapy should be initiated in suspected thrombin suggest novel approaches to endoscopic intervention
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variceal hemorrhage prior to endoscopic diagnosis and intervention. in gastric variceal bleeding. However, these therapies need further
Selective splanchnic vasoconstriction has the added advantage of validation, are only done in specialized centers, are not FDA approved,
diverting blood flow from the splanchnic circulation to the systemic and can lead to serious complications such as embolism, infection,
circulation, thereby improving systemic blood pressure. In particular, and death. In the setting of gastric variceal bleeding, EVL may be
improved renal perfusion could prevent or ameliorate the hepatorenal attempted to obtain initial hemostasis. However, given the limited
syndrome. success of endoscopic hemostasis, the emergent application of non-
The current agent of choice in the United States is the somatostatin endoscopic interventions should be anticipated, which may include
analog octreotide. Somatostatin and its analogs inhibit the release of balloon tamponade (using the Linton-Nachlas tube), transjugular
vasodilator hormones such as glucagon, thereby indirectly causing intrahepatic portosystemic shunt (TIPS), and surgery.
splanchnic vasoconstriction and decreased portal inflow. Although
octreotide has a longer half-life than somatostatin, its therapeutic effi- Complications of Endoscopy: Most complications have been associated
cacy is obtained only with a continuous infusion; the recommended dose with EST, and the advent of variceal band ligation (EVL) has decreased
is a 50 µg IV bolus, followed by an infusion of 50 µg/hour for 5 days. A the incidence of complications significantly after therapeutic endos-
meta-analysis of trials of octreotide has demonstrated improved con- copy. Following endoscopic intervention, local complications include
trol of bleeding compared with other therapies, including the previous ulceration, dysmotility, and stricture formation, and regional compli-
agent of choice, vasopressin. Furthermore, the adverse extrasplanchnic cations include esophageal perforation and mediastinitis. In addition,
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vasoconstrictive effects observed with vasopressin, such as myocardial both EST and EVL increase the risk of developing portal hypertensive
and cerebral ischemia, are not observed with octreotide. gastropathy (PHG) and its bleeding sequelae because blood is shunted

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