Refractory Variceal Bleeding: Approach To Management (Mini Review)

Short Review

Acute variceal bleeding (AVB) is seen in 50-70% of patients with cirrhosis & portal hypertension (PHT) [1]. Over the time the severity

of the bleeding and complications related to bleeding have significantly reduced due to improvement in clinical management, better

availability of vasopressor drugs, improved endoscopic therapies as well as due to availability of definitive treatment options such as

TIPS and liver transplantation. About 10-20% patients do not respond to initial management (failure to control bleeding within 48 hrs)

and develop re bleeding within 5 days of starting the therapy (initial control of bleeding), these patients can be defined to have refractory

variceal bleeding. The causes for refractory variceal bleeding are a. severe liver disease (high MELD-Na and CTP score) b. coagulopathy

(increased PT, INR and low platelets) c. post EVL band ulcers (PEBU’s) or slippage of bands [2-4].

Failure to control bleeding leads to poorer outcome due to a. worsening liver failure b. development of organ dysfunction due to

hypovolemia and progressive shock c. systemic sepsis and increased gut translocation of bacteria.

The management in this group of patients depends upon the general condition of the patient and the liver disease status. There was a

recent study which showed that endoscopic appearance of the varices after banding can determine the outcomes in addition to MELDNa

score [4].

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