Cause of death in 20% of cirrhotics (Nejm 1966;275:61)

Lab: Hem:Clotting studies, serial hemoglobin/hematocrit

Rx:

Preventive maneuvers (Ann IM 1992;117:59; Nejm 1987;317:893)

• Propranolol, naldolol or other ß-blocker to pulse <60, decreases recurrent bleeding and 1st bleeds, and increases survival by 5-10% (Nejm 1999;340:1033 vs 988; 1991;324:1532) but does not prevent new varicies developing (Nejm 2006;354:2254)
• Isosorbide (Isordil) 20-40 mg po bid as good (GE 1993;104:1460), or used w ß-blocker is better than sclero rx (Nejm 2001;345:648)
• Transjugular intrahepatic portosystemic stent (TIPS) shunt placement works like other shunting procedures w a 5% significant bleeding cmplc rate and 25% encephalopathy induction rate; used for both bleeding and intractable ascites (Nejm 2010;362:2370, 2421; Jama 1995;273:1824; Nejm 1994;330:165, 182)
• Surgical shunt for recurrent bleeding, not prophylactically

of acute bleeding:

• Somatostatin analogs like: octreotide 50 mg/h iv continuous drip (Nejm 1995;333:555 vs BMJ 1995;10:310) prior to endoscopy to help decr acute bleeding but no incr in survival (ACP J Club 2005;143:16)
• Endoscopic ligation (Ann IM 1995;123:280; Nejm 1992;326:1527) as good as surgery (which has a 50% survival), better than medical rx after a bleed but not used prophylactically if has never bled (Nejm 1991;324:1779), also better than sclerosis (Ann IM 1993;119:1)
• Sclerosis of varices directly via gastroscope (Nejm 1987;316:11); also useful preventively after a bleed (Ann IM 1997;126:849, 858)
• Open esophageal stapling if sclero rx fails (Nejm 1989;321:857)