Management Of Acute Variceal Bleeding Research Articles

Octreotide versus Terlipressin as Adjuvant to Endoscopic Variceal Band Ligation in Bleeding Oesophageal Varices: A Systematic Review and Meta-Analysis

Background: Acute variceal bleeding (AVB) is a critical complication of portal hypertension, contributing significantly to mortality worldwide. Pharmacological interventions, including terlipressin and octreotide, have evolved to manage AVB, yet consensus on their comparative effectiveness remains elusive. This study conducts a comprehensive systematic review and meta-analysis of randomized control trials (RCTs) comparing terlipressin and octreotide in the management of AVB, aiming to provide insights into their relative benefits. Methods: This study included RCTs with head-to-head comparisons of terlipressin and octreotide. The search strategy covered PubMed, Scopus, and Cinahl databases, and the included studies involved adult patients with confirmed AVB undergoing endoscopic variceal band ligation (EVBL). Results: Seven RCTs meeting inclusion criteria were included in the meta-analysis. The assessed outcomes were: achieving haemostasis within 24 h, rebleeding rate, and mortality rate. The pooled analysis revealed no statistically significant differences between terlipressin and octreotide in achieving haemostasis (OR: 1.30, p = 0.23), rebleeding rates at 5 days (OR: 0.7, p = 0.23), and mortality at 42 days (OR: 0.9, p > 0.5). Conclusion: This meta-analysis suggests that terlipressin and octreotide exhibit similar efficacy in reducing bleeding, rebleeding rates, and mortality when used as adjuvants to EVBL in AVB. Clinicians are encouraged to consider individual patient characteristics and the broader clinical context when choosing between these agents. Future research should focus on addressing existing evidence gaps and enhancing understanding of variables influencing EVBL outcomes.

Timing of endoscopy for acute variceal bleeding in patients with cirrhosis (CHESS1905): A nationwide cohort study.

Endoscopy plays an important role in the management of acute variceal bleeding (AVB) in patients with cirrhosis. This study aimed at determining the optimal endoscopy timing for cirrhotic AVB. Patients with cirrhosis with AVB across 34 university hospitals in 30 cities from February 2013 to May 2020 who underwent endoscopy within 24 hours were included in this study. Patients were divided into an urgent endoscopy group (endoscopy <6 h after admission) and an early endoscopy group (endoscopy 6-24 h after admission). Multivariable analysis was performed to identify risk factors for treatment failure. Primary outcome was the incidence of 5-day treatment failure. Secondary outcomes included in-hospital mortality, need for intensive care unit, and length of hospital stay. A propensity score matching analysis was performed. In addition, we performed an analysis, in which we compared the 5-day treatment failure incidence and the in-hospital mortality among patients with endoscopy performed at <12 hours and 12-24 hours. A total of 3319 patients were enrolled: 2383 in the urgent endoscopy group and 936 in the early endoscopy group. After propensity score matching, on multivariable analysis, Child-Pugh class was identified as an independent risk factor for 5-day treatment failure (HR, 1.61; 95% CI: 1.09-2.37). The incidence of 5-day treatment failure was 3.0% in the urgent endoscopy group and 2.9% in the early group ( p = 0.90). The in-hospital mortality was 1.9% in the urgent endoscopy group and 1.2% in the early endoscopy group ( p = 0.26). The incidence of need for intensive care unit was 18.2% in the urgent endoscopy group and 21.4% in the early endoscopy group ( p = 0.11). The mean length of hospital stay was 17.9 days in the urgent endoscopy group and 12.9 days in the early endoscopy group ( p < 0.05). The incidence of 5-day treatment failure in the <12-hour group was 2.3% and 2.2% in the 12-24 hours group ( p = 0.85). The in-hospital mortality was 2.2% in the <12-hour group and 0.5% in the 12-24 hours group ( p < 0.05). The data suggest that performance of endoscopy within 6-12 or within 24 hours of presentation among patients with cirrhosis with AVB led to similar treatment failure outcomes.

Metástasis de origen pulmonar de localización inusual

Esophageal varices are present in majority of the patients with hepatic cirrhosis at the time of diagnosis, especially in those with advanced liver disease. Variceal size, red wale marks on varices, and advanced liver disease are risk factors for variceal hemorrhage. Esophageal variceal ligation (EVL) is a standard endoscopic procedure in the management of acute variceal bleeding and is beneficial in the primary and secondary prophylaxis of esophageal variceal bleeding. Multiband devices are commonly used for EVL. Various endoscopic techniques, common clinical scenarios, and procedure-related complications in EVL are described in the video manuscript provided. This article is part of an expert video encyclopedia.

Position statement of Hepatology Society, Dhaka, Bangladesh, on the management of acute variceal bleeding in a resource-limited setting

Variceal bleeding is one of the important signs of decompensation in patients with cirrhosis of the liver. It is always a medical emergency and sometimes results in death. Every year many patients die due to acute bleeding worldwide. The outcome depends on bleeding and its complications as well as the severity of the underlying liver disease. Careful volume resuscitation, administration of antibiotics and vasoactive drugs, and early endoscopic therapy prevent re-bleeding and death. People living in rural areas are first referred to a district hospital from the Upazila health complex for any medical emergency. So, commencing the resuscitation process as well as administration of the vasoactive drug (terlipressin) at the first attending hospital before being referred to a higher center will decrease the mortality in patients presenting with acute variceal bleeding.

Investigation report on endoscopic management of esophagogastric variceal bleeding by Chinese endoscopists.

Background:Esophagogastric variceal bleeding (EGVB) is a potentially life-threatening complication of portal hypertension. Endoscopic treatment combined with pharmacotherapy remains the mainstay in the management of acute variceal bleeding.Aim:This article intends to highlight the potential differences in the endoscopic management of EGVB in China.Methods:A cross-sectional descriptive study was conducted. Endoscopists from 85 hospitals in 62 cities from 26 provinces were contacted by email. The items in questionnaire involved academic experience, screening, esophagogastric varices (EGV) classification, emergency treatment, and primary and secondary prophylaxis of EGVB by endoscopists with different lengths of experience.Results:A total of 85 questionnaires were collected. There was no statistical difference in the selection of items (P < .05 indicated statistical significance). The majority of endoscopists (95.29%) offered EGV screening for patients with liver cirrhosis. The location, diameter, and risk factor classification was selected by 82.35% of endoscopists. Endoscopy + medication was preferred (42.35%) for the primary prophylaxis of moderate-to-severe EGVs. There was no statistical difference in emergency intervention time for active EGVB (P > .05). The response “patients receive emergency endoscopic intervention within 12 hours” was selected by 61.2% of the endoscopists. The preferred emergency treatment for EGVB was combination treatment (40%). Tissue adhesive embolization was selected for the treatment of gastric variceal bleeding by 74.12% of endoscopists; transjugular intrahepatic portosystemic stent shunt/percutaneous transhepatic variceal embolization were selected as remedial measures by 48.23% to 52.94% of endoscopists. In addition, 67.06% of endoscopists elected to perform secondary prophylaxis and treatment within 1 week after hemostasis. Endoscopy and endoscopy + medication were selected by 44.71% and 49.41% of endoscopists, respectively, for secondary prophylaxis. The choice of laboratory indicators did not differ with length of experience.Conclusions:There was no statistical difference in the endoscopic management of EGVB among Chinese endoscopists. The selection of diagnosis/treatment schemes was mainly based on guidelines and physician experience.

Management of varices and variceal hemorrhage in liver cirrhosis: a recent update.

Cirrhosis consists of two main stages: compensated (asymptomatic) and decompensated, the latter with a higher mortality. Variceal hemorrhage, together with ascites or encephalopathy, or both, are events that define cirrhosis decompensation and are driven by portal hypertension. The approach and management of patients with compensated cirrhosis has been mostly focused on preventing variceal hemorrhage in those who have high-risk varices on endoscopy. Recent studies suggest a paradigm shift aimed at preventing all decompensating events, not only variceal hemorrhage, in patients with cirrhosis and clinically significant portal hypertension identified via noninvasive measures such as liver stiffness and platelet count. In these patients, nonselective beta-blockers have been shown to prevent ascites (the most common decompensating event) and variceal growth. Variceal hemorrhage has a high mortality rate and even though advances in diagnostic approach and standard of care over the past decades have led to a decrease in mortality, it is still high with a 6-week mortality rate of 15–20%. Survival has improved with the preemptive placement of the transjugular intrahepatic portosystemic shunt in patients at high risk of failing standard therapy. In this review, we provide an overview of the pathophysiology and bases for therapy of portal hypertension and varices, the diagnostic approach and management of compensated cirrhosis with clinically significant portal hypertension, and the management of acute variceal hemorrhage as well as prevention strategies for variceal hemorrhage recurrence.

Iatrogenic Esophagopleural Fistula After the Management of Acute Variceal Hemorrhage With Minnesota Tube Placement

ABSTRACTAn esophagopleural fistula (EPF) is a rare condition. EPFs are typically of spontaneous, iatrogenic, or neoplastic origin. A 50-year-old man with hepatitis C and alcoholic cirrhosis presented with a history of recurrent variceal hemorrhage requiring esophageal banding, Minnesota tube placement, and a transjugular intrahepatic portosystemic shunt. His hospital course after esophageal perforation and EPF was complicated by acute respiratory failure and empyema, necessitating intubation and thoracostomy tube placement. To the best of our knowledge, this is the first reported case of EPF secondary to Minnesota tube placement. The EPF completely healed after endoscopic repair.

Role of early transjugular intrahepatic portosystemic stent-shunt in acute variceal bleeding: An update of the evidence and future directions.

Variceal bleeding is a serious complication of cirrhosis and portal hypertension. Despite the improvement in management of acute variceal bleed (AVB), it still carries significant mortality. Portal pressure is the main driver of variceal bleeding and also a main predictor of decompensation. Reduction in portal pressure has been the mainstay of management of variceal bleeding. Transjugular intrahepatic porto-systemic stent shunt (TIPSS) is a very effective modality in reducing the portal hypertension and thereby, controlling portal hypertensive bleeding. However, its use in refractory bleeding (rescue/salvage TIPSS) is still associated with high mortality. “Early” use of TIPSS as a “pre-emptive strategy” in patients with AVB at high risk of failure of treatment has shown to be superior to standard treatment in several studies. While patients with Child C cirrhosis (up to 13 points) clearly benefit from early-TIPSS strategy, it’s role in less severe liver disease (Child B) and more severe disease (Child C > 13 points) remains less clear. Moreover, standard of care has improved in the last decade leading to improved 1-year survival in high-risk patients with AVB as compared to earlier “early” TIPSS studies. Lastly in the real world, only a minority of patients with AVB fulfil the stringent criteria for early TIPSS. Therefore, there is unmet need to explore role of early TIPSS in management of AVB in well-designed prospective studies. In this review, we have appraised the role of early TIPSS, patient selection and discussed future directions in the management of patients with AVB.

Recent Advances in the Management of Acute Variceal Hemorrhage.

Gastrointestinal bleeding is one of the most relevant causes of death in patients with cirrhosis and clinically significant portal hypertension, with gastroesophageal varices being the most frequent source of hemorrhage. Despite survival has improved thanks to the standardization on medical treatment aiming to decrease portal hypertension and prevent infections, mortality remains significant. In this review, our goal is to discuss the most recent advances in the management of esophageal variceal hemorrhage in cirrhosis with specific attention to the treatment algorithms involving the use of indirect measurement of portal pressure (HVPG) and transjugular intrahepatic portosystemic shunt (TIPS), which aim to further reduce mortality in high-risk patients after acute variceal hemorrhage and in the setting of secondary prophylaxis.

Fresh frozen plasma transfusion in acute variceal haemorrhage: Results from a multicentre cohort study

Fresh frozen plasma (FFP) transfusion is often used in the management of acute variceal haemorrhage (AVH) despite best practice advice suggesting otherwise. We investigated if FFP transfusion affects clinical outcomes in AVH. We performed a retrospective cohort study of 244 consecutive, eligible patients admitted to five tertiary health care centres between 2013 and 2018 with AVH. Multivariable regression analyses were used to study the association of FFP transfusion with mortality at 42days (primary outcome) and failure to control bleeding at 5days and length of stay (secondary outcomes). Patients who received FFP transfusion (n=100) had higher mean Model for End Stage Liver Disease (MELD) score and more severe variceal bleeding than those who did not received FFP transfusion (n=144). Multivariable analysis showed that FFP transfusion was associated with increased odds of mortality at 42days (odds ratio [OR] 9.41, 95% confidence interval [CI] 3.71-23.90). FFP transfusion was also associated with failure to control bleeding at 5days (OR 3.87, 95% CI 1.28-11.70) and length of stay >7days (adjusted OR 1.88, 95% CI 1.03-3.42). The independent association of FFP transfusion with mortality at 42days persisted when the cohort was restricted to high-risk patients and in patients without active bleeding. Fresh frozen plasma transfusion in AVH is independently associated with poor clinical outcomes. As this an observational study, there may be residual bias due to confounding; however, we demonstrate no benefit and potential harm with FFP transfusions in AVH.

Updated strategies in the management of acute variceal haemorrhage.

This article reviews the most recent studies regarding the management of acute esophageal variceal haemorrhage. New randomized control trials and meta-analyses confirmed the role of early transjugular intrahepatic portosystemic shunt (TIPS) in the management of acute variceal haemorrhage in Child-Pugh C (10-13) and B patients with active bleeding. A recent randomized controlled trial focused on the duration of vasoactive therapy showed no difference between 2 and 5 days of octreotide. A randomized trial showed decreased use of blood products for the correction of coagulopathy using a thromboelastography-guided approach (vs. conventional parameters) as well as decreased bleeding rates when compared with standard of care. A meta-analysis found that for rescue of variceal bleeding, self-expanding metallic stents were more efficacious and safer than balloon tamponade. In addition, studies showed that Child-Pugh C patients and those with hepatic vein pressure gradient more than 20 were at the highest risk of treatment failure, while model for end-stage liver disease was highly predictive of in-hospital mortality. In patients with severe coagulopathy and uncontrolled bleeding, TEG-based transfusion strategies are recommended. Antibiotics should be used for all cirrhotic patients presenting with upper gastrointestinal bleeding, but should be tailored in accordance to local resistance patterns. Early TIPS for high-risk patients has been shown to have a significant survival benefit. Certain aspects of the management of variceal bleeding remain poorly studied such as the role of early TIPS in Child-B patients as well as strategies for rescue therapy in patients who are not TIPS candidates, and require further investigation.

Endoscopic management of acute oesophageal variceal bleeding within 12 hours of admission is superior to 12–24 hours

ABSTRACT Background: Acute oesophageal variceal haemorrhage (AOVH) is a medical emergency. The American Association for the Study of Liver Diseases recommends endoscopy management as soon as possible and not more than 12 hours after presentation. The United Kingdom guidelines recommended endoscopy for unstable patients with severe acute upper gastrointestinal bleeding immediately after resuscitation and within 24 hours of admission. We aimed to evaluate the outcome of endoscopic management of AOVH in less than 12 hours compared to 12–24 hours post admission. Methods: 297 patients with AOVH were divided into groups depending on the timing of the endoscopic management: 180 within 12 h of admission and 117 patients at 12–24 hours of admission. Routine clinical and laboratory data were collected. Results: Compared to patients with endoscopic management at 12–24 hours (mean 16 hours), patients with endoscopic management within 12 hours (mean 8.3 hours) of admission had fewer hospital stay days (P = 0.001), significant reduction of ammonia levels (P < 0.0001) and significant improvement in associated hepatic encephalopathy grade 25 (p = 0.048). There were no major clinical events in the 12-hour group, but 8 events in the 12–24 hour group (p < 0.01). Conclusion: Endoscopic management of acute variceal bleeding within 12 hours of admission is superior to endoscopic management at 12–24 hours of admission regarding reduction of hospital stay, ammonia levels, correction of hepatic encephalopathy, re-bleeding and mortality rate, hence, reducing the cost of treatment benefiting patient satisfaction and improving hospital bed availability.

Vasoactive Agents for the Management of Acute Variceal Bleeding: A Systematic Review and Meta-analysis.

Vasoactive agents with endoscopic therapy are used to treat acute variceal bleeding (AVB). There are two main groups of vasoactive agents: terlipressin and vasopressin (T-V), and octreotide and somatostatin (O-S). However, the benefit/harm balance is unclear. Our aim was to assess the efficacy and safety of T-V versus O-S for the management of AVB. We performed a systematic search for randomized controlled trials (RCTs) in PubMed, Scopus, and CENTRAL. Our main outcomes were mortality and adverse events. Secondary outcomes were bleeding control, rebleeding, blood transfusion, hospital stay. We evaluated the certainty of evidence using GRADE methodology. We included 21 RCTs. The risk of mortality (RR: 1.01; 95%CI: 0.83-1.22), bleeding control (RR: 0.96; 95%CI: 0.91-1.02; I 2 =53%), early rebleeding (RR: 0.91; 95%CI: 0.66-1.24: I 2 =0%), late rebleeding (RR: 0.94; 95 CI: 0.56-1.60; I 2 =0%), blood transfusion (MD: 0.04; 95%CI: -0.31-0.39; I 2 =68%) and hospital stay (MD: -1.06; 95%CI: -2.80-0.69; I 2 =0%) were similar between T-V and O-S groups. Only 15 studies reported adverse events, which were significantly higher in the T-V compared to the O-S group (RR 2.39; 95%CI: 1.58-3.63; I 2 =57%). The certainty of evidence was moderate for the main outcomes, and low or very low for others. In cirrhotic patients with AVB, those treated with T-V had similar mortality risk compared to O-S. However, the use of T-V showed an increased risk of adverse events compared to O-S.

The role of pre-emptive Transjugular Intrahepatic Portosystemic Shunt in acute variceal bleeding: a literature review.

The development of portal hypertension has serious implications in the natural history of liver cirrhosis, leading to complications such as ascites, hepatic encephalopathy and variceal bleeding. The management of acute variceal bleeding has improved in the last two decades, but despite the advances in endoscopic methods the overall prognosis remains poor, particularly within a subgroup of patients with more advanced disease. The role of Transjugular Intrahepatic Portosystemic Shunt (TIPSS) is a well-established method of achieving haemostasis by immediate portal decompression; however, its use in an emergency setting as a rescue strategy is still associated with high mortality. It has been shown that ‘early’ use of TIPSS as a pre-emptive strategy in a patient with acute variceal bleed in addition to the standard of care confers superior survival outcomes in a subgroup of patients at high risk of treatment failure and death. The purpose of this review is to appraise the literature around the indications, patient selection, utility, complications and economic considerations of pre-emptive TIPSS.

Peptide-based therapy in portal hypertension.

To summarize the use of gastrointestinal peptides in the management of portal hypertension. Vasoactive peptides are commonly used in the management of acute variceal hemorrhage and hepatorenal syndrome, which are portal hypertensive complications of cirrhosis. The main vasoactive peptides that are used are somatostatin and its long-acting analogue octreotide, and vasopressin and its analogue terlipressin. Early initiation of vasoactive peptides in the management of acute variceal hemorrhage and hepatorenal syndrome is associated with improved outcomes. Octreotide is the available vasoactive peptide in the Unites States. Recent developments and ongoing clinical trials may improve our understanding of hepatorenal syndrome and influence the use of vasoactive peptides, particularly terlipressin. Here, we review the literature on the use of vasoactive peptides in the management of acute variceal hemorrhage and hepatorenal syndrome.

A META-ANALYSIS COMPARING THE EFFICACY AND SAFETY OF TERLIPRESSIN AND OCTREOTIDE IN THE MANAGEMENT OF ACUTE VARICEAL BLEEDING

Objective: Various clinical trials have compared terlipressin and octreotide in the management of acute variceal bleed, but their results have been inconsistent. Therefore, the present meta-analysis was performed to compare the clinical efficacy and safety of terlipressin and octreotide and gather the strength of evidence regarding their use in variceal hemorrhage.&#x0D; Methods: Randomized control trials were identified using PubMed search engine and Cochrane clinical trial register (from 1994 to 2019). Initial hemostasis rate, rebleeding rate on the 5th day, and overall mortality rate during the study period were studied. The extracted data were analyzed using review manager 5.3 software. Odds ratio with 95% confidence intervals (CI) was estimated for the dichotomous outcomes.&#x0D; Results: A total of six randomized control trials were identified. Through comparisons of data for terlipressin and octreotide groups, we found no statistically significant differences in the initial hemostasis rate, rebleeding rate on the 5th day, and overall mortality rate between the different treatment approaches.&#x0D; Conclusion: The comparison of terlipressin and octreotide showed them to be equally effective and safe therapeutic agents in patients of acute variceal bleeding. Further, evidence from the future randomized controlled trials with higher quality and larger sample sizes is needed to confirm these findings.

Management of Acute Variceal Bleed by Esophageal Variceal Ligation in an Unconventional Position—An Urban-Center Insight

Abstract Background Acute variceal bleed is a fatal complication in patients with liver cirrhosis, and it is important to achieve hemostasis at the earliest. Endoscopic variceal ligation (EVL) is a preferred modality in controlling variceal bleed. The blood pool in esophagus and oozing of blood from varices cause hindrance for variceal ligation leading to failure of therapy. In sitting position, it is hoped that visualization of esophagus may be better. With this background, EVL of patients in sitting position was done and results were analyzed. Methods Cirrhotics presenting with hematemesis and/or melena were included in the study. Clinical and endoscopic parameters were assessed. Among them, patients having hypotension and hepatic encephalopathy were excluded. Initial endoscopic assessment was done in left lateral position. In case of obscured visualization of esophagus due to flooding, if time taken to achieve hemostasis &gt; 5 minutes, position was changed to sitting from left lateral decubitus. Patients with isolated gastric variceal and ulcer bleed were further excluded. Results Among 78 acute bleed patients selected, 41fulfilled the inclusion criteria for the study. During endoscopy, in 20 patients, EVL was done in left lateral decubitus position with head end elevation. Twenty-one patients were shifted from conventional left lateral position to sitting posture. Study revealed that patients undergoing EVL in sitting position had better visibility aiding the procedure and no aspiration during the procedure. There was no difference in the left lateral with head raised or without it. Duration of EVL was comparable to that of nonbleeders and additional sclerotherapy was not required in any case in both the groups. Following the procedure, patients were observed for 5 days. There was no failure of therapy which was analyzed according to Baveno VI consensus. However, there was delayed complication in one case due to sepsis and metabolic acidosis causing death. Conclusion This study suggests, in acute variceal bleed cases, EVL in sitting position aids in better visibility and helps in achieving hemostasis early with least complications.

Is additional 5-day vasoactive drug therapy necessary for acute variceal bleeding after successful endoscopic hemostasis?: A systematic review and meta-analysis.

Background:Vasoactive drugs and endoscopic therapy have been widely used in the management of acute variceal bleeding of cirrhosis patients. The current standard regimen of vasoactive drugs is in combination with endoscopic therapy and continues for up to 5 days; however, the necessity of vasoactive drugs after endoscopic hemostasis was still controversial. Therefore, we conducted a systematic review and meta-analysis to evaluate the efficacy and optimal duration of adjuvant vasoactive drugs after hemorrhage control by endoscopic therapy.Methods:A search was conducted of PubMed, EMBASE, and Cochrane Library databases until June, 2018. Lan DeMets sequential monitoring boundary was constructed to assess the reliability and conclusiveness of our major results.Results:Seven studies (639 patients) and 4 studies (435 patients) were included in the analyses to evaluate the efficacy and optimal duration of adjuvant vasoactive drugs therapy, respectively. Our analyses showed that adjuvant vasoactive drugs facilitated endoscopic hemostasis and reduced very early re-bleeding rate both in sclerotherapy (risk ratio [RR] 0.51, 95% confidence interval [CI] 0.34–0.78, P = .23, I2 = 31%) and band ligation (RR 0.48, 95% CI 0.27–0.83, P = .07, I2 = 62%). However, the 3 to 5-day therapy duration was not superior to a shorter course in very early re-bleeding rate and mortality rate in 42 days (RR 1.77, 95% CI 0.64–4.89, P = .70, I2 = 0%; RR 0.95, 95% CI 0.43–2.13, P = .81, I2 = 0%, respectively).Conclusion:Additional 5-day vasoactive drug after endoscopic hemostasis may significantly ameliorate very early re-bleeding rate, However, the 3 to 5 days’ adjuvant regimen was not superior to a shorter course.

Esophageal Stenting for Refractory Esophageal Variceal Bleeding

Esophageal variceal bleeding is a lethal complication in patients with cirrhosis. Occasionally, esophageal variceal bleeding is refractory to standard endoscopic and pharmacologic therapies. We discuss a case of bleeding esophageal varices that was treated with esophageal stenting as a bridge to emergent transjugular intrahepatic portosystemic shunt (TIPS). A 55-year-old female with a past medical history of alcoholic and hepatitis C virus (HCV) cirrhosis presented with large volume hematemesis. One week previously, she was admitted with hematemesis and during upper endoscopy, five bands were placed treating large distal esophageal varices. During the current admission, labs were remarkable for a hemoglobin of 8.8, down from 9.6 two days earlier, INR of 1.7, platelets of 146, and MELD-Na of 22. The patient was transfused one unit of packed red blood cells (PRBC) and maintained on intravenous octreotide and pantoprazole. During endoscopy, multiple large varices were found in the middle and distal third of the esophagus. Two bands were placed on the esophageal varices in the distal esophagus. One band detached immediately and large volume bleeding ensued. Placement of additional bands at the bleeding site was not possible due to scarring. A temporizing covered esophageal stent was deployed across the gastroesophageal junction to achieve hemostasis by tamponade while emergent TIPS was arranged. Meanwhile, her vitals remained stable and there were no further episodes of hematemesis. She underwent emergent TIPS with retrograde embolization of the esophageal collaterals, which she tolerated well. The plan was to remove the esophageal stent in two weeks. Unfortunately, the patient continued to decompensate and passed away during liver transplantation surgery. Current standard management of acute variceal bleeding includes adequate resuscitation, vasoactive medications, acid suppression, antibiotic prophylaxis, and endoscopic banding. Previously balloon tamponade was used and had complications including migration, aspiration, and tissue ischemia with mortality rates around 20%. Placement of self-expanding metal stents (SEMS) is an effective option for refractory variceal bleeding due to its high initial bleeding control rate, low rebleeding rate, and lower rate of adverse events compared to balloon tamponade. Our case revealed that SEMS is an effective temporizing measure for refractory esophageal variceal bleeding until TIPS can be performed.1981_A Figure 1. Large esophageal varices with presence of postbanding ulcer1981_B Figure 2. Wallflex stent deployed

Prevention and management of gastroesophageal varices

Bleeding from gastroesophageal varices is a serious complication in patients with liver cirrhosis and portal hypertension. Although there has been significance improvement in the prognosis of variceal bleeding with advancement in diagnostic and therapeutic modalities for its management, mortality rate still remains high. Therefore, appropriate prevention and rapid, effective management of bleeding from gastroesophageal varices is very important. Recently, various studies about management of gastoesophageal varices, including prevention of development and aggravation of varices, prevention of first variceal bleeding, management of acute variceal bleeding, and prevention of variceal rebleeding, have been published. The present article reviews published articles and practice guidelines to present the most optimal management of patients with gastroesophageal varices.