Management of Acute Variceal Upper Gastrointestinal Bleeding

Immediate Resuscitation and Medical Therapy

Portal hypertension is defined as a pathological increase in portal pressure with hepatic venous pressure gradient (HVPG) >5 mmHg, with clinically significant portal hypertension (CSPH) occurring at HVPG ≥10 mmHg 6
The gold standard for diagnosing and quantifying portal hypertension is measurement of the HVPG 6

Gastrointestinal bleeding related to portal hypertension is the most frequent complication 7
Ascites is the most common complication, reducing 5-year survival from 80% to 50% 6
Splenomegaly and hypersplenism lead to reduced blood cell counts 7
Gastroesophageal varices and portal hypertensive gastropathy are common manifestations 7
Portosystemic collaterals can be detected on abdominal imaging 7
Hepatic hydrothorax/pleural effusion occurs in 0%-8% of cases 8

HVPG measurement is the gold standard, with normal values ranging from 1-5 mmHg, portal hypertension >5 mmHg, and CSPH ≥10 mmHg 6
Non-invasive assessment methods include imaging-based tests like transient elastography and blood-based tests like APRI 6
Diagnostic paracentesis with measurement of ascitic fluid albumin/protein, neutrophil count, culture, and amylase is recommended when ascites is present 9
Abdominal ultrasound can evaluate liver appearance, splenomegaly, and portosystemic collaterals 9

The American College of Radiology recommends TIPS for refractory ascites 8
Non-selective beta-blockers (NSBBs) are ineffective in mild portal hypertension (HVPG >5 but <10 mmHg) 10
NSBBs, including carvedilol, can be considered for clinically significant portal hypertension (HVPG ≥10 mmHg) without varices 10
Combination of endoscopic therapy and pharmacological treatment improves hemostasis and reduces mortality in variceal bleeding 10
Liver transplantation should be considered for all patients with decompensated cirrhosis as definitive treatment 10, 6

Previous gastrointestinal bleeding and size of esophageal varices predict future gastrointestinal bleeding 7
HVPG reduction of ≥10% after therapy is associated with decreased risk of first variceal hemorrhage 6
Age, ascites, extension to superior mesenteric vein, and severity of underlying conditions predict mortality 7