Therapeutic Targets
- Prevention of complications and sequelae such as esophageal variceal hemorrhage (bleeding from veins in the wall of the esophagus)
- In esophageal variceal bleeding: hemostasis.
- Avoidance of sepsis (blood poisoning).
- Avoidance of recurrent bleeding (bleeding again).
Therapy recommendations
- Primary prophylaxis:
- Objective: avoid first esophageal variceal bleeding; risk of first esophageal variceal bleeding is approximately 30%.
- Indications for primary prophylaxis: increased risk of bleeding = large varices (variceal diameter > 5 mm), (“red color signs” or stage III).
- Permanent use of non-selective beta-blockers, e.g. propranolol; bleeding risk can thus be reduced by about 50%.
- In acute esophageal variceal bleeding:
- Vasoactive substances such as terlipressin, somatostatin(-derivatives) – vasopressin is used less and less due to significant side effects!
- Bleeding can often be stopped at least in the short term by medication.
- In the therapy of acute esophageal variceal bleeding should always also antibiosis (eg, with ciprofloxacin) to prevent sepsis; duration of therapy 5-7 days; in addition, the risk of early bleeding recurrence is reduced.
- Suitable for long-term therapy are:
- Propranolol (non-selective beta-blocker) – first-line agent; decrease heart rate and cardiac output (HRV) and decrease splanchnic blood flow (visceral blood flow).
- Secondary prophylaxis, as recurrent bleeding is common!
- In early bleeding recurrences: renewed administration of vasoactive substances as well as antibiotic infection prophylaxis.
- The risk of subsequent recurrent bleeding can be minimized by, among other things, the permanent use of beta-blockers.
- After variceal hemorrhage: prophylaxis of coma hepaticum (hepatic coma)!
- Suction of the bloody stomach contents to reduce the protein load on the liver.
- Intestinal cleansing
- Administration of lactulose (orally and as an enema).
- Taking rifaximin (non-absorbable antibiotic).
Other notes
