Acute variceal haemorrhage: Practice guidelines and real-life management

Abstract

Variceal haemorrhage is a life-threatening event in the course f cirrhosis of the liver. In the 1970s and 1980s, the short term (30 ays to 6 weeks) mortality for variceal bleeding was in the order f 40–50%, with 6-weeks rebleeding rates of over 30%. In subseuent years, great progress has been made in the management f this medical emergency; such progress has been made possile by improvements in general supportive care as well as in the pecific management of variceal bleeding, such as the introduction f emergency endoscopic treatments (first sclerotherapy and subequently rubber band ligation), the early use of vasoactive drugs vasopressin, terlipressin, somatostatin, and octreotide), the adopion of antibiotic prophylaxis and of restrictive transfusion policies, nd the availability of emergency transjugular intrahepatic portoystemic shunt (TIPS) for patients failing (or at high risk for failure f) first line therapies. Indeed, progressive decrease over the years f rebleeding and mortality rates after variceal haemorrhage has een reported from several countries. As an example, in a nationide study from Sweden [1] the survival of patients hospitalized for esophageal varices increased steadily and significantly between 969 and 2002. The Authors attributed the improvement in surival to the “improved acute treatment and secondary prophylaxis f the hospitalized patients with varices”. Similar results have been eported in the United Kingdom, France, the United States and enmark. In 1990, the scientific evidence concerning the diagnosis nd management of variceal haemorrhage was critically evaluated y a faculty including several world experts in the field in a consenus workshop that took place in Baveno, Italy. Recommendations or clinical practice based on the conclusions of the workshop (aka he Baveno recommendations) were published in the Journal of epatology. Since then, the Baveno recommendations have been pdated in consensus workshops held every 5 years, to incorpoate the new evidence as soon as it was published. The most recent aveno workshop (Baveno V) took place in 2010 [2]. The Baveno ecommendations are widely accepted, and in subsequent years nspired the publications of similar guidelines by scientific societies