Acute variceal hemorrhage in a patient with cirrhosis is a life-threatening decompensating event. Variceal hemorrhage — mainly from esophageal or gastric varices — is associated with 10%–20% mortality at six weeks.
This protocol applies when upper GI endoscopy (with band ligation for esophageal varices or sclerotherapy for gastric varices) has failed to achieve control of bleeding. Failure of endoscopic bleeding control is the criterion that escalates management to the interventions described here.
When endoscopic hemostasis cannot be achieved, management pivots to mechanical tamponade as a bridge to a more definitive interventional procedure — with the choice of intervention guided by patient risk profile and variceal anatomy. The full decision algorithm, criteria, and sequencing are in the structured protocol.
DOI: 10.1016/j.jceh.2022.03.002
Variceal hemorrhage, mainly from esophageal or gastric varices, is a life-threatening acute decompensating event associated with 10%–20% mortality at six weeks.
In case of failure to control bleeding or refractory bleeding despite pharmacologic and endoscopic therapy, tamponade with Sengastaken-Blakemore or Minnesota tube can be considered as a bridge to more definitive therapies such as TIPS.
Balloon occluded retrograde transvenous obliteration (BRTO) can be considered for GOV2, isolated gastric varices or ectopic varices depending on variceal anatomy and availability of local expertise.
Patients with Child-Pugh class C (<14 points) or Child-Pugh class B (>7 points) with active bleeding or HVPG >20 mmHg during variceal bleed have a high risk of re-bleeding and should be considered for the placement of pTIPS in 24–72 h.
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