variceal bleeding ffh med-2
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Varicose veins that develop in the esophagous as a result of
elevated pressure in the venous system of the abdomen.
Upper G.I. Bleeding is a Medical Emergency associated with high mortality.
80-90% bleed from esophageal varices & not from other sources.
Overall mortality of first bleed is 50% mainly due to patientsdying before they reach hospital.
50-70% patients experience a re-bleeding episode during
hospitalisation.
At least, a third will re-bleed within 6 weeks of discharge fromhospital.
No more than third will survive beyond one year.
Introduction
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Esophageal Varices
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Varices in the distal esophagus as viewed through an endoscope
Esophageal Varices
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About 30% cirrhotic patients with demonstrable varices manifest
bleed.
Almost all bleeding episodes occur within 2 years of initialobservation.
Once bleeding occurs 40-50% cirrhotic patients die within 6months.
There is an 80% incidence of re-bleeding once patient bleedsfrom varices.
Mortality seen with every re-bleeding is about 60%.
Every re-bleeding even if treated successfully requires a lot ofhospital resources, especially blood.
Facts & Figures
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Causes of Portal Hypertension
Liver Cirrhosis (alcoholic, biliary, posthepatitis)
Non-cirrhotic portal fibrosis/ Portal
hypertension
Schistosomiasis
Budd-Chiari Syndrome
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1stDegree Varices
2ndDegree Varices
3rdDegree Varices
Predictors of Bleeding in EV
- Size
- Red Spots
- Child Pugh Score
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EMERGENCY MANAGEMENT OF UPPER G.I. BLEEDING
AT FAMILY PHYSICIANS CLINIC
MINOR BLEEDING
(BP Stable, Pulse < 100/min)
History of past bleeding attacks,
jaundice/NSAIDs, other
medications
Inject Octreotide 50 mcg* i.v. stat
at the site of visit
No further bleeding
Patient remains stable
Consult G.I. Specialist/Hospital for
further evaluation & Endoscopy
MAJOR BLEEDING
Hypotensive Shock, Patient Collapse
Maintain i.v. line with
Normal Saline & Plasma
Expanders
Inject Octreotide 50 mcg stat i.v.AND START
I.V. infusion of Sandostatin
25 mcg/hour
HOW?
(Add 3 ampoules of 100 mcg
Sandostatin in 500 c.c.
dextrose/water 5% in 12 hours)
URGENTLY SHIFT PATIENT
TO HOSPITAL
* Sandostatin (Octreotide) is available as (a) 0.05 mg injection (50 mcg ampoule) (b) 0.1 mg injection (100 mcg ampoules)
For further Specialized Management please refer a Gastroenterologist
Note:
Upper G.I. Bleeding may present with
Vomiting of fresh blood
Black color loose stools
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Prevention
- Beta blockers and nitrates
Acute variceal bleeding
- Vasopressin
- Vasopressin Analogue
- Somatostatin
- Somatostatin Analogue
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Acts by decreasing portal pressure by
constricting splanchnic blood vessels
LIMITATIONS
- Short half life
- Systemic vasoconstriction
- MI and mesenteric Ischaemia
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Same mode of action as vasopressin
Longer half life
Fewer side effects
LIMITATIONS
- Less effective in controlling active bleeding andpreventing re-bleeding
- No reduction in transfusion requirements- Should be use with trans-dermal Nitroglycerineto counter cardiac side effects
(Hepatology 1993, vol.18, p 61-65)
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Contrindicated in IHD
(Management of Portal Hypertension and Budd Chiari Syndrome,
Andrew K Burroughs)
ECG and BP must be monitored
Can only be used when ICU facilities are
available
(Terlipressin package insert)
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Acts by selectively reducing hepatic blood flow
and wedge hepatic venous pressure
LIMITATIONS
- Shorter half life
- Necessitates continuous IV infusion
- Rebound bleeding
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Same pharmacologic effects as Somatostatin
Much longer half life
Significantly reduces intra-variceal pressure
Decreases the inflow of blood to the portalsystem
Increased selectivity
Potency greater than that of Somatostatin
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Advantages of Sandostatin (Octreotide)
Longer plasma half-life
(about 1-2 hours)
Longer duration of action
S.C. injection which can be
self-administered by the patient
More potent
More selective
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USES AND BENEFITS
Sandostatinis effective in control of acute variceal bleeding
at 24 hours and stops variceal haemorrhage in 80% of
patients.
Sandostatinis equally effective as endoscopic therapy in
mild, moderate and severe disease.
Sclerotherapy is not available at all centres and depends
upon the technical expertise.
Sandostatinwhen used prior to sclerotherapy produces an
effective Holding & prevents re-bleeding during the first 4
hours especially when used with sclerotherapy.
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Sandostatinis more effective than other modalities in theemergent control of active variceal bleeding.
Sandostatinreduces the transfusion requirements as
compared to other pharmacological treatment modalities i.e
1 unit versus 3 units within 48 hours.
Sandostatinhas an excellent safety profile than other
treatments. It is well tolerated & has fewer side effects.
Due to absence of systemic circulatory effects Sandostatin
can be used without special monitoring.
USES AND BENEFITS
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A recent meta-analysis evaluated 13 randomized trials ofoctreotide v/s several alternative interventions for varicealhemorrhage[21] These 13 trials included a total of 1077 patients(numbers ranged from 40 to 199 total patients per trial). Theendpoints analyzed involved assessments made at the end of therecorded follow-up, rather than at arbitrary times during the firstfew hours of hospitalization. The primary endpoints were:
Total rebleeding
Mortality
Complications
This study defined lack of control of bleeding as any episode of
rebleeding during the follow-up period It defined major complications as hypertension or hypotension,
cardiac or intestinal ischemia, arrhythmias, pneumonia, pulmonaryedema, or any side effect that required termination of treatment
Corley DA, Cello JP, Adkisson W, et al. Octreotide for acute esophageal variceal
bleeding: a meta-analysis. Gastroenterology. 2001;120:946-954.
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Meta-analysis demonstrated that most studies favor octreotide vs alternative
therapy (vasopressin/terlipressin, placebo/no therapy, and sclerotherapy) for
the control of bleeding in acute variceal hemorrhage
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0
10
20
30
40
50
60
70
80
90
100
Octreotide
Vaso/Terli
Sclero/Band
Placebo
Balloon
Major
Any
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Octreotide was associated with fewer Major Complicationthan vasopressin/ Terlipressin
A trend towards Morality benefitespecially against
Balloon or Vasopressin Comparable in efficacyto Emergency Sclerotherapy and
comparable or better than other modalities. Mostcommon dosage regime in studies was 2550 g IV for48- 120 hours
Addition of Octreotideto Sclerotherapy producedsignificant better initial bleeding control and Rebleedingrates and small survival advantage compared withvasopressin/Terlipressin
(Gastroenterology 2001, 120, p 946-954)
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50 mcg intravenous as bolus in case of acute bleeding
Maintain i.v. line and start
50 mcg per hour for 5 days by continous i.v. infusion
Emergency therapy required at Family Physicians Clinic
for a patient with projectile bloody vomiting reports
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Conclusion
At present, available clinical evidence suggests that, because of
its efficacy & lack of major side effects Sandostatin most closely
fulfil the requirements of the ideal vasoactive drugfor the
control of acute variceal bleeding.
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