Acute esophageal variceal hemorrhage
The following measures may be considered to stop acute esophageal variceal hemorrhage:
- Rubber band ligation (GBL) – This is performed endoscopically and is considered the method of choice. It is associated with significantly fewer complications than variceal sclerotherapy.
- Variceal sclerotherapy (variceal sclerotherapy) – This involves injecting a sclerosant (hardening agent), such as polidocanol, which leads to sclerosis due to an inflammatory stimulus. Possible complications include perforation (piercing), strictures (high-grade narrowing), pleural effusion (pathological (abnormal) accumulation of fluid between the pleura parietalis (pleura of the chest) and pleura visceralis (pleura of the lungs)), pericardial effusion (accumulation of fluid in the pericardium), fever, and bacteremia. The complication rate is 10%.
- Sondent tamponade – for persistent (ongoing) bleeding to compress the varices; balloon probe: inflation of a balloon that compresses the blood vessels. The Sengstaken-Blakemore probe (for varices of the terminal esophagus and cardiac region (transition area from the esophagus to the stomach)) or the Linton Nachlas probe (for varices of the gastric fundus) are recommended for this purpose. This is followed by endoscopic therapy.Note: Using the Sengstaken-Blakemore probe, bleeding control is successful in approximately 90% of cases.The use of a compression probe is associated with the following risks and should therefore only be used in the short term (complication rate 10-20%):
- Esophagitis (inflammation of the esophagus).
- Esophageal necrosis (death of the esophageal mucosa).
- Esophageal rupture (rupture of the esophagus)
- Pneumonia (pneumonia) due to the passage of gastric juice into the lungs.
- Self-expanding metal stent (with plastic coating) – e.g., Ella stent; placed in the distal esophagus (part of the esophagus that lies in the abdominal cavity) for 1-2 weeks; considered a back-up procedure
Secondary prophylaxis – recurrence prophylaxis
The risk of recurrent bleeding (bleeding again after the first bleeding) is high. Within the first 10 days after the first hemorrhage, it is 35%, and within one year after the first hemorrhage, the recurrence rate is 70%. Consequently, secondary prophylaxis is mandatory and is most effective with combination therapy of rubber band ligation and drug therapy (nonselective beta blockers).
In a multicenter study, 187 patients with Child-Pugh A/-B liver cirrhosis and successful acute esophageal variceal bleeding were randomized to two study arms:
- Implantation of a transjugular portosystemic stent shunt (TIPS; as so-called “early TIPS”) Number (n) = 92.
- Drug therapy with a nonselective beta-blocker (NSBB; propranolol) and/or nitrates; number (n) = 95.
RESULT: After a median follow-up interval of 2.5 years, significantly fewer recurrent bleeding events (7%) occurred after implantation of a TIPS compared with drug therapy (26%, p = 0.002). However, all-cause mortality was unchanged in both groups with a slightly increased rate of adverse treatment effects in the TIPS group.CONCLUSION: Thus, drug therapy remains therapy of first choice!
