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Management of the patient with hemorrhaging esophageal varices.
JAMA. 1986 Sep 19; 256(11):1480-4.JAMA

Abstract

Bleeding from esophageal varices remains a difficult clinical problem, carrying a high likelihood both of rebleeding and of mortality. The initial approach requires adequate but not overly vigorous volume replacement with blood and other fluids. Once the patient is resuscitated, upper gastrointestinal endoscopy should be performed to establish the source of bleeding. Both endoscopic variceal sclerotherapy and balloon tamponade appear to be effective in achieving temporary control of acute ongoing hemorrhage from esophageal varices. The value of intravenous vasopressin remains controversial. Rebleeding can be prevented in most patients by shunt surgery. However, surgery carries both considerable early morbidity and mortality (related mainly to the severity of the underlying liver disease) and substantial longer-term morbidity and mortality from hepatic encephalopathy and liver failure. The role of pharmacologic agents (eg, propranolol) intended to prevent variceal hemorrhage by reducing portal pressure remains to be established. At present, we recommend use of endoscopic variceal sclerotherapy for the control of active variceal bleeding, with employment of balloon tamponade and intravenous vasopressin if sclerotherapy is successful. Emergency shunt surgery should be reserved only for those patients whose bleeding cannot be controlled by these other means. For prevention of rebleeding in Child class C patients, we attempt to obliterate the varices by repeated endoscopic sclerotherapy. Patients who have two to three episodes of rebleeding despite this approach are considered for shunt surgery. For better-risk patients who do not have ascites, which is difficult to control, we are currently recommending a distal splenorenal shunt. Alternatively, repeated endoscopic variceal sclerotherapy is used for these better-risk patients (Child class A or B) in some centers, with shunt surgery reserved for patients who continue to rebleed. Which approach to preventing rebleeding in the better-risk patient is more effective, as well as the role of pharmacologic therapy with propranolol or other agents, remains to be settled by well-controlled randomized clinical trials.

Authors

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Pub Type(s)

Journal Article
Review

Language

eng

PubMed ID

3528543

Citation

Cello, J P., et al. "Management of the Patient With Hemorrhaging Esophageal Varices." JAMA, vol. 256, no. 11, 1986, pp. 1480-4.
Cello JP, Crass RA, Grendell JH, et al. Management of the patient with hemorrhaging esophageal varices. JAMA. 1986;256(11):1480-4.
Cello, J. P., Crass, R. A., Grendell, J. H., & Trunkey, D. D. (1986). Management of the patient with hemorrhaging esophageal varices. JAMA, 256(11), 1480-4.
Cello JP, et al. Management of the Patient With Hemorrhaging Esophageal Varices. JAMA. 1986 Sep 19;256(11):1480-4. PubMed PMID: 3528543.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Management of the patient with hemorrhaging esophageal varices. AU - Cello,J P, AU - Crass,R A, AU - Grendell,J H, AU - Trunkey,D D, PY - 1986/9/19/pubmed PY - 1986/9/19/medline PY - 1986/9/19/entrez SP - 1480 EP - 4 JF - JAMA JO - JAMA VL - 256 IS - 11 N2 - Bleeding from esophageal varices remains a difficult clinical problem, carrying a high likelihood both of rebleeding and of mortality. The initial approach requires adequate but not overly vigorous volume replacement with blood and other fluids. Once the patient is resuscitated, upper gastrointestinal endoscopy should be performed to establish the source of bleeding. Both endoscopic variceal sclerotherapy and balloon tamponade appear to be effective in achieving temporary control of acute ongoing hemorrhage from esophageal varices. The value of intravenous vasopressin remains controversial. Rebleeding can be prevented in most patients by shunt surgery. However, surgery carries both considerable early morbidity and mortality (related mainly to the severity of the underlying liver disease) and substantial longer-term morbidity and mortality from hepatic encephalopathy and liver failure. The role of pharmacologic agents (eg, propranolol) intended to prevent variceal hemorrhage by reducing portal pressure remains to be established. At present, we recommend use of endoscopic variceal sclerotherapy for the control of active variceal bleeding, with employment of balloon tamponade and intravenous vasopressin if sclerotherapy is successful. Emergency shunt surgery should be reserved only for those patients whose bleeding cannot be controlled by these other means. For prevention of rebleeding in Child class C patients, we attempt to obliterate the varices by repeated endoscopic sclerotherapy. Patients who have two to three episodes of rebleeding despite this approach are considered for shunt surgery. For better-risk patients who do not have ascites, which is difficult to control, we are currently recommending a distal splenorenal shunt. Alternatively, repeated endoscopic variceal sclerotherapy is used for these better-risk patients (Child class A or B) in some centers, with shunt surgery reserved for patients who continue to rebleed. Which approach to preventing rebleeding in the better-risk patient is more effective, as well as the role of pharmacologic therapy with propranolol or other agents, remains to be settled by well-controlled randomized clinical trials. SN - 0098-7484 UR - https://www.unboundmedicine.com/medline/citation/3528543/Management_of_the_patient_with_hemorrhaging_esophageal_varices_ L2 - https://jamanetwork.com/journals/jama/fullarticle/vol/256/pg/1480 DB - PRIME DP - Unbound Medicine ER -