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home - Liver - Treatments - Varices post bleed prophylaxis Written by Dr Sebastian Zeki
Knowledge


Knows the indications for liver transplantation appropriate timing of
referral for assessment and outcomes after transplantation

Understands the long-term management of liver transplant recipients
including complications of immunosuppression and management of
recurrent disease

Skills
Can identify potential candidates for liver transplantation as well as
demonstrating an understanding of why patients with end-stage liver
disease are not appropriate candidates for liver transplantation

Has detailed understanding of the transplant process will
be required while training in specialist units and their satellites

Behaviours
Displays confidence that they can identify all potential candidates for
liver transplantation refer at the appropriate time and contribute to
life-long follow-up of liver recipients

Varices post bleed prophylaxis

Risks for death:-Severity of liver disease.-Severity of bleeding.-Early re-bleeding.-Infection.-Renal dysfunction.-Cardiorespiratory disease. Written by Dr Sebastian Zeki Recommend beta blockers with banding as primary therapy for secondary prophylaxis of esophageal variceal haemorrhage Recommendations Failure= Recommendations (highest risk if within 6 wks after initial bleed) 40% recur after obliteration Post Bleed Prophylaxis Risks for re-bleeding:-Severity of liver disease.-Active bleeding in endoscopy.-Increased HVPG (>16 mmHg).-Bacterial infections. Within six hours: a)Transfusion of >4 units of blood and b) Inability to achieve an increase in systolic blood pressure of 20 mmHg or to 70 mmHg or more, and/or c)A pulse reduction to <100/min or a reduction of 20/min from the baseline pulse rate.After six hours:a)Haematemesis,b)Reduction in bp> 20 mmHg from the 6h point and/or c)Increase of pulse rate > 20/min from the 6 hour point on 2 readings 1 hour apart, d)Transfusion of >2 units of blood (over and above the previous transfu-sions) required to increase the hct >27 % or Hb to > 9g/dL.Rebleeding= Any bleeding > 48 hours after tadmission for variceal hemorrhage and is separated by > 24 hour bleed-freeEarly rebleeding= if occurred within 6 weeksThe highest risk for failure to control bleeding or early rebleeding is in the first 72 hours after the onset of bleeding. Short-term (maximum 7 days) antibiotic prophylaxis with oral norfloxacin or iv cipro should be instituted in any patient with cirrhosisand GI hemorrhage.Give terlipressin for 3-5 days after diagnosis confirmed.TIPS indicated for uncontrolled bleeding/rebleeding with balloon tamponade as a temporizingmeasure (maximum 24 hours) For gastric fundal varices use tissue adhesives or EVL ad TIPS if cant control it. -All patients need secondary prophylaxis-Combination of nonselective B-blockers at maximum tolerated dse plus EVL is the best option-EVL should be repeated every 1-2 weeks until obliteration with the first surveillance EGD performed 1-3 months after obliteration and then every 6-12 months to check for variceal recurrence.-Consider TIPS in Child A or B patients if not responsive to medical and endoscopic treatment-In centers where the expertise is available, surgical shunt can be considered in Child A patients.-Patients who are otherwise transplant candidates should be referred to a Pharmacological Therapy:Beta blockers plus band ligation —combination therapy reduces overall bleeding and variceal rebleeding and variceal recurrence more than EVL alone but no mortality reduction.Beta blockers plus sclerotherapy —These are more effective in preventing rebleeding than sclerotherapy alone but band ligation is preferred to sclerotherapy.Beta blockers plus oral nitrates —This shows possibly small survival benefit over beta blockers alone.

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