Variceal Bleeds
Somatostatins and vasopressins
Two classes of drugs are widely used in the management of variceal haemorrhage. These include somatostatins (Octreotide) and vasopressins (Terlipressin).
Somatostatins cause a relaxation of vascular smooth muscle and reduce portal venous pressure. Vasopressins cause arterial vasoconstriction, reducing portal venous pressure but at the risk of end-organ ischaemia. A systematic review has shown no reduction in the number of deaths with somatostatins. However, Terlipressin was noted to be safe and effective. Terlipressin has been shown to reduce blood loss from actively bleeding varices and confers a 34% relative risk reduction in risk of mortality. Terlipressin is also more convenient as it can be given as a bolus.
Learning Bite
Terlipressin should be given in ED to any patient with suspected variceal bleeding.
Vitamin K
A Cochrane review concludes that there is no evidence of efficacy for the administration of Vitamin K in patients with liver disease who have an upper GI haemorrhage.
Antibiotics
20% of cirrhotic patients with acute variceal bleeding will develop a bacterial infection within 48 hours [LEE].
All patients with acute upper gastrointestinal bleeding where the source is suspected or confirmed varices should be given prophylactic therapy with antibiotics such as ciprofloxacin or ceftriaxone.
Learning Bite
Broad Spectrum antibiotics (usually Ceftriaxone) should be given early in ED to any patient with suspected variceal bleeding.