Esophageal Varices: The Daily PANCE Blueprint

The answer is D, Propranolol

Nonselective beta-adrenergic blockers (e.g. Propranolol) are recommended to reduce the risk of first variceal hemorrhage in patients with medium/large varices and patients with small varices who either have variceal red wale marks or advanced cirrhosis.

Pearls

• Esophageal varices are dilated veins in the distal esophagus or proximal stomach caused by elevated pressure in the portal venous system, typically from cirrhosis
• Often found in lower 1/3 of the esophagus and can extend into gastric veins
• Often presents with hematemesis (bloody vomiting) with a coffee ground appearance and melena (dark stools) secondary to metabolized RBCs passing into the lower GI tract
• Patients may initially present with vital sign instability: tachycardia/hypotension ⇒ may bleed massively but cause no other symptoms
• Rarely hematochezia (more common in lower GI bleeds)

Diagnosis

• Perform emergent upper GI endoscopy in all patients with GI bleed (once the patient is stabilized) 
• Endoscopy is diagnostic and can be therapeutic
• Serum labs: hemoglobin and hematocrit, platelet count

Treatment

• Treatment consists of intravenous octreotide which is a somatostatin analog that decreases portal blood flow.
• Antibiotic prophylaxis with IV ciprofloxacin is given for a week to lower the risk of a bacterial infection, and in severely-ill individuals, IV ceftriaxone is given instead.
• An upper endoscopy is done within 12 hours of presentation and variceal ligation is done. That’s where small elastic bands are placed on the varices to stop them from bleeding.
• Another option is endoscopic sclerotherapy– meaning that a sclerosant solution like sodium morrhuate is injected in the varices endoscopically.
• If there’s massive bleeding or if endoscopic therapy fails to stop the bleeding, then balloon tamponade is done using a Blakemore tube-which has two balloons- one balloon for the lower part of the esophagus and another balloon for the stomach, as well as a third lumen, through which gastric aspiration is done. This applies direct pressure which can stop an ongoing bleed. It can only be used for about 48 hours because the pressure can further harm the esophagus and there’s often rebleeding once the balloons are deflated and removed.
• When endoscopic approaches fail, another procedure is a transjugular intrahepatic portosystemic shunt or TIPS, which creates a path between the portal and systemic circulation in order to lower the portal pressure.