Diagnosis and management of variceal bleeding in the critically ill

Abstract Cirrhosis is the most common cause of portal hypertension, which subsequently leads to development of gastroesophageal varices (GEV). Generally, presence of GEV correlates with the severity of cirrhosis and variceal haemorrhage can develop when hepatic venous pressure gradient exceeds 10–12 mmHg. The gold standard for diagnosis and often treatment of GEV is oesophagogastroduodenoscopy (OGD). Management of GEV is divided into primary prophylaxis, acute haemorrhage control, and secondary prophylaxis. Primary prophylaxis includes surveillance OGD and endoscopic intervention based on the size of the varices. Management of acute variceal haemorrhage includes resuscitation and endoscopic interventions. Basic resuscitative measures to maintain haemodynamic stability, vasoconstricting agents to decrease portal pressure, and the use of prophylactic antibiotics. Endoscopic intervention includes any of variceal band ligation, variceal sclerotherapy, and variceal obturation. Radiological or surgical portosystemic shunting markedly reduces portal pressure and are clinically effective therapy for patients who fail endoscopic or pharmacological therapy. Balloon tamponade is effective in temporarily controlling oesophageal variceal haemorrhage in over 80% of patients. Its use should be restricted to patients with uncontrollable bleeding, where more definitive therapy is planned within 24 hours. Secondary prophylaxis includes endoscopy plus pharmacological therapy of non-selective β−blockers.