APASL Consensus on Acute Variceal Bleeding

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• APASL Consensus on Acute Variceal Bleeding
• 31-Jan-2009 to 01-Feb-2009
• FINAL RECOMMENDATIONS

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Lacunae in current definition of acute variceal
bleedsession -2 (definitions)

• Ming-Chih Hou, M.D.

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(No Transcript)
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Acute Variceal Bleeding

• In a known or suspected case of PHT presence of
• Hematemesis within last 24 h of presentation
• and / or ongoing melena, with last melenic stool
  within last 24 hr
• The time frame for the acute bleeding episode
  should be 48 h
• Acute bleed may be active/inactive
• Active bleed is a state which is defined
  endoscopically, when Spurting or oozing is seen
  from the varix

Level of evidence- 5D
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Consensus definition

• Rebleed-
• - development of fresh
  haemetemesis/ malena after 48 hr of t0 (time of
  admission)
• Very Early Rebleed- Recurrence of bleed from 48
  to 120 hr
• Early Rebleed- Recurrence of bleed from day 6
  to 42days
• Late rebleed- Recurrence of bleeding after 6
  wks from t0

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Consensus definition- Failure to control
bleeding

• One criterion defines failure whichever occurs
  first within 48hr
• If patient develops fresh haemetemesis after 2 hr
  of combination (drugsEVL) therapy
• gt2 g drop in Hb (6 drop in Ht) if no
  transfusion is administered
• Death
• The first two criteria would require
  modification of therapy
• The utility of Adjusted Blood-transfusion
  Requirement Index (ABRI) 0.75 at any time point
  to define failure to control bleeding is being
  evaluated.

Level of evidence- 3 C
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Definition of rebleeding

• A new hematemesis (or new melena) after 48 hr of
  t0 and after a period of 24 h of hemodynamic
  stability. (D,5)

Clinically Significant Rebleeding (D, 5)

• Hematemesis / melena or in the minority of
  patients who have a NG tube in place, aspiration
  of greater than 100 ml of fresh blood represents
  rebleed
• plus
• Decrease 2 g of Hb if no BT is given OR
• ABRI ? 0. 5 at any time point

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Recommendation

• Current and future studies are encouraged to
  incorporate APASL-2009 Baveno criteria, and
  evaluate end points using both sets of criteria.
  The threshold of ABRI defining failure requires
  validation.

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Defining acute variceal bleedsession -2
(definitions)

• Dr Anoop

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Index Bleed
First episode of bleeding with which the patient
present to the hospital RECENT BLEED Refers to
a significant bleed which occurred within 6 weeks
of presentation PAST BLEED Refers to a
significant bleed which occurred more than 6
weeks of presentation 5 D Level of evidence- 5D
Baveno II
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TERMS TO BE DELETED

• TRIVIAL BLEED
• SPONTANEOUS CESSATION OF BLEED

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Defining control of acute variceal bleed and
failure of therapysession -2 (definitions)

• Justin wo

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Successful therapy for acute variceal bleed

• Commentary
• An ideal successful therapy for acute variceal
  bleeding should achieve control of bleeding,
  prevention of complications and reduction of
  bleeding related mortality.

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Definition of control of acute variceal bleeding

• Control of acute variceal bleeding refers to
  cessation of bleeding with hemodynamic stability
  for 24 hrs after therapy
• In patients with active bleeding on endoscopy,
  cessation of bleeding should be confirmed at the
  end of the procedure (5D)

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Severity indices for variceal bleedingwhat
should be the variables in ideal severity
scoresession -2 (definitions)

• Dr Wasim

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Predictors of severity of variceal bleed

• Severity of variceal bleed and rebleed depend on
  several factors
• Size and morphology of varices,
• Platelets count,
• Hematocrit level at presentation, Packed RBCs
  transfusion
• HVPG,
• Degree of liver failure,
• Ascites,
• Portal vein thrombosis,
• Alcoholic liver disease,
• CTP Class/ score
• Infection.

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Proposed Variables in Severity Score
Systolic pressure Systolic pressure gt 90 mm Hg
and no Postural drop ? 0 Systolic pressure gt 90
mm Hg with Postural drop ? 1 Systolic pressure
lt 90 mm Hg ? 2 CTP Class A ?
0 B ? 1 C ? 2 Platelets count gt
100000 ? 0 lt100000 ? 1 Infections
Absent ? 0 Present ? 1 Active bleed
at endoscopy Absent ?0 Present ?1
AGE,HVPG,ABRI/BLOOD TRANFUSION ,To be estimated
at 6 and 24hrs,and needs validation
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Prognosis assessmentsession -2 (definitions)

• Ming-Chih Hou, M.D.

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Predictors of treatment failure
using current treatment standards immediate
vasoactives, antibiotic prophylaxis,
emergent/urgent endoscopic treatment ALL
(UNIVARIATE/MULIVARIATE ANALYSIS TO BE DONE)
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Predictors of treatment failure (2)

• using current treatment standards ALL AGREE
  
• UNIVARIATE AND MULTIVARIATE ANALYSIS TO BE DONE

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Predictors of early rebleeding
using current treatment standards
Multivariate analysis to be done
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Predictors of mortality
using current treatment standards
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Predictors of mortality
using current treatment standards liver
cirrhosis with UGI bleeding
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Difficult to treat patients To be debated again

• Best treatment of variceal bleeding requires
  multimodalities including pharmacologic,
  endoscopic, radiologic and surgical treatment.
  Guidelines are consolidated for most cases but
  still lacking for some difficult cases such as
• EV bleeding with large GV
• EV bleeding with difficult overtube insertion or
  difficult multibands ligator insertion
• EV bleeding with severe fibrosis or extensive
  ulceration.
• Massive EV bleeding without identified site
• Isolated gastric variceal bleeding
• Active bleeding from PHG
• Ectopic variceal bleeding
• Bleeding refractory to drug, endoscopic and
  shunting Tx
• THESE PATIENTS MAY REQUIRE HIGHER
  EXPERTISE/FACILITIES FOR MANAGEMENT
• DIFFERENCE BETWEEN TREATMENT NAÏVE/PRIOR TREATED
  PATIENTS needs more data to answer this question

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Diagnosis Evaluation of Patients with Acute
Variceal Bleedsession -3 (Initial Management)
APASL Consensus on Acute Variceal Bleeding New
Delhi 31.1.09-1.2.09

• Hock-Foong LUI

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HOW DO WE DIAGNOSE ESOPHAGEAL VS GASTRIC VS
ECTOPIC VARICEAL BLEEDING?

• Gold Standard ENDOSCOPY 3,C
• I. Oesophageal Variceal Bleeding
• One of the following is indicative of acute
  oesophageal variceal bleed
• Direct visualization of blood issuing from an
  oesophageal varix usually spurting
• Presence of a sign of recent bleed on a varix
• white nipple sign or overlying clot
• Presence of oesophageal varices with red signs
  (risk factors for bleed) AND presence of blood in
  the stomach in the absence of another source of
  bleed
• Presence of oesophageal varices with red signs
  AND clinical signs of upper GI bleed , without
  blood in the stomach
• 3,C

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HOW DO WE DIAGNOSE ESOPHAGEAL VS GASTRIC VS
ECTOPIC VARICEAL BLEEDING?

• Gold Standard ENDOSCOPY
• II. Gastric Variceal Bleeding
• Classification The Sarin Classification
• One of the following endoscopic findings
  constitutes acute gastric variceal bleeding
• Direct visualization of blood issuing from a
  gastric varix spurting or oozing
• Presence of a sign of recent bleed over a gastric
  varix
• overlying clot or white nipple sign
• Presence of gastric varices with red signs (risk
  factors for bleed) AND presence of blood in the
  stomach in the absence of another source of
  bleed/or stigmata of recent bleed on esophageal
  varices
• Presence of gastric varices with red signs AND
  clinical signs of upper GI bleed melaena or
  haematemesis without blood in the stomach

3,C
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HOW DO WE DIAGNOSE ESOPHAGEAL VS GASTRIC VS
ECTOPIC VARICEAL BLEEDING?

• Gold Standard ENDOSCOPY
• III. Ectopic Variceal Bleeding
• Location includes duodenal, choledochal, omental,
  stomal and rectal
• One of the following endoscopic findings
  constitutes acute ectopic variceal bleeding
• Direct visualization of blood issuing from varix
  usually spurting
• Presence of a sign of recent bleed
• white nipple sign or overlying clot
• 3,C

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HOW DO WE ASSESS FOR AMOUNT OF BLOOD LOSS?

• Haematocrit/Haemoglobin
• Transfusion requirement
• AMERICAN COLLEGE/ICU CRITERIA MAY BE USED BUT
  TARGETS HAVE TO DEFINED TO PLAN MANAGEMENT
  STRATEGIES (5D)
• ABRI MAY BE OF LIMITED VALUE (5D)

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Assessment of blood loss
Level of evidence 5D
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When to clinically suspect PHT bleed

• Issues
• Examination
• palpable firm left hepatic lobe
• gynaecomastia, testicular atrophy,
  parotidomegaly,
• jaundice, Vascular spiders, leuconykia,
• palmar erythema, signs of hepatic encephalopathy,
  
• presence of abdominal wall collateral
  circulation,
• ascites, leg oedema and splenomegaly

Level of evidence 5D
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HOW SHOULD WE ASSESS FOR BLEEDING ACTIVITY, CAUSE
OF BLEEDING, UNDERLYING DISEASE AND ASSOCIATED
CO-MORBIDITIES?

• ASSESSMENT OF UNDERLYING DISEASE
• All patients presenting for the first time should
  have a thorough work-up to assess for anatomical
  site of portal hypertension and aetiology of this
  cause and potential precipitating agents such as
  infections,drugs etc.
• Known cases of chronic liver disease presenting
  with variceal bleed should have an updated
  assessment looking for potential causes of
  decompensation.
• Portal vein thrombosis
• Interval development of hepatocellular carcinoma
• Sepsis esp. spontaneous bacterial peritonitis
• Local factors
• e.g. recent ingestion of NSAIDs
  
• 5, D

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HOW SHOULD WE ASSESS FOR BLEEDING ACTIVITY, CAUSE
OF BLEEDING, UNDERLYING DISEASE AND ASSOCIATED
CO-MORBIDITIES?

• ASSESSMENT OF COMORBIDITIES
• Complications related to cirrhosis.
• Hepatorenal syndrome
• Ascites
• Hepatic encephalopathy
• HCC
• Comorbidities unrelated to cirrhosis
• Infection
• Renal
• Cardiorespiratory
• 5, D

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Variceal bleeding

• 70 of all upper gastrointestinal bleeding
  episodes in patients with portal hypertension
• Esophageal Varices
• Gastric Varices
• Ectopic Varices

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HOW DO WE EVALUATE FOR PRECIPITATING FACTORS?

• Precipitating factors are
• Increase in portal hypertension
• Portal vein thrombosis
• HCC
• ACLF
• INFECTION
• Drugs
• ALCOHOL

• ASSESSMENT
• Careful attention to drug history during history
  taking
• Routine blood tests
• Imaging
• Diagnostic ascitic tap

5, D
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Monitoring of patients with acute variceal
bleedsession -3 (Initial Management)

• H J de Silva

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RecommendationsROLE OF NG TUBE IN MONITORING

• Routine use of NG tube is not recommended but it
  may be used in cases of hepatic encephalopathy
  (5D)

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Role of CVP monitoring

• CVP MONITORING IS HELPFUL IN SELECTED PATIENTS
• Elderly
• Cardiovascular comorbidity
• Active bleeding on endoscopy
• Presence of shock
• Renal failure (impending or present)
• To optimize decisions concerning volume of fluid
  replacement. (2a, C).
• Jugular approach is better so preferred.
• CVP alone may not accurately predict fluid
  responsiveness. (2a, B).
• Presence of active bleeding and those with
  elevated PT should require ICU care
• 
  
  (4D)
• 
  
• Patients with predictors of high mortality should
  be managed in ICU

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Recommendations

• Routine use of a pulmonary artery catheter in the
  management of patients with shock is not
  recommended. (1a, B).

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General Management of Acute Variceal
Bleedingsession -3 (Initial Management)

• Jose D. Sollano

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PROPOSED RECOMMENDATIONS/STATEMENTS

• Initial resuscitative measures include volume
  replacement by blood transfusion to maintain a
  hemoglobin level of approximately 8 g/dL, a
  systolic blood pressure of 90-100 mm Hg and a
  heart rate below 100 beats per minutes.
• (Level of Evidence 2b Grade A)

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PROPOSED RECOMMENDATIONS/STATEMENTS

• Protection of the airway by elective intubation
  is recommended in severe uncontrolled variceal
  bleeding, hepatic encephalopathy(grade III,IV),
  in the presence of aspiration pneumonia and when
  there is difficulty maintaining oxygen saturation
  above 90.
• (Level of Evidence 2b Grade A)

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PROPOSED RECOMMENDATIONS/STATEMENTS

• Administration of a short course of antibiotic
  prophylaxis (5-7dyas) with i.v. ceftriaxone
  (CHECK THE DOSE g/day), decrease the rate of
  bacterial infections and increase survival in
  patients with variceal hemorrhage.
• (Level of Evidence 1a Grade A)

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PROPOSED RECOMMENDATIONS/STATEMENTS

• The use of recombinant activated factor VII
  (rFVIIa) in cirrhotic patients with acute
  variceal bleeding is not currently recommended.
• (Level of Evidence 1b Grade A)

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How should the patients be resuscitated

• Maintain systolic BP 90-100 mm Hg
• Hb maintain b/w 7-8 gm/dl.
• Hct b/w 21-24
• Level of
  evidence 2A

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Management of coagulopathy and thrombocytopenia
Consensus statement no recommendations can be
made regarding the management
Level
of evidence 5D
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Volume replacementsession -3 (Initial
Management)

• Roerto de Franchis

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Volume Replacement To send by email

• What should be the fluid management and volume
  replacement policy in patients with acute
  variceal bleeding?
• Fluid replacement should be used very
  conservatively and cautiously
• Role of crystalloids versus colloids?
• Colloids are preferred and crystalloids should be
  avoided particularly saline,maintanence fluids is
  by glucose infusion
• How much fluid to administer? How to monitor?
• Need answer from Dr Roberto
• How to determine transfusion requirement?
• What blood products to transfuse? How to
  transfuse?
• PRBC IS PREFERRED
• What should be the target hemoglobin?
• (7-8GM)
• What is the role of ABRI?
• CVP to be monitered IN SEVERE BLEEDING,TARGET
  systolic B.P 90-100mm Hg and CVP 1-5 mm Hg ( cm
  of water to be given)

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Blood Volume RestitutionBaveno IV Consensus
Statements

• Blood volume restitution should be done
  cautiously and conservatively, using plasma
  expanders to maintain haemodynamic stability and
  PRBC to maintain the haemoglobin at approximately
  7- 8 g/dL, depending on other factors such as
  patients co-morbidities, age, haemodynamic
  status and presence of ongoing bleeding (1b A)
• Level of
  evidence 2A

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Pharmacological Therapy Role and
Resultssession -3 (Initial Management)

• Soon Koo Baik

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Recommendations

• Pharmacological therapy using vasoactive drugs
  should be initiated as soon as variceal
  hemorrhage is suspected (1 A)
• Door to needle time should be lt30 min and once
  variceal bleed is confirmed combination therapy
  should be strated
• 2. Terlipressin should be the first choice for
  pharmacological therapy when available,and there
  is no contraindiaction(1 A). However,
  terlipressin is not usable in some area such as
  North America where somatostatin and vapreotide
  are other drugs preferred
• 3. In patients with esophageal variceal bleeding,
  pharmacological therapy should be maintained for
  2-5 days (1 A)
• Dose of terlipressin 2mg every 4 hrly to be used.

BASELINE ECG TO BE DONE IF TERLIPRESSIN IS
PLANNED
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Endoscopic treatment for acute variceal
bleeding Role, timing and results
Endoscopic treatment of acute esophageal variceal
bleedRole Results and timing session -4
(Endoscopy)
Dr Hitoshi Maruyama Chiba University Graduate
School of Medicine, JAPAN
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Role of endoscopy in Acute variceal bleed

• All UGIE in patient with acute UGI bleed should
  be with an intent to provide endotherapy. (5D)

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Timing of endoscopy

• No studies comparing urgent vs emergent UGIE.
• Door to scope time In patients with AVB
  endotherapy to be done as soon as possible,
  preferably with in 6 hr of admission T0 (5D)

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• Combination of a vasoactive drug endoscopic
  therapy is the first line therapy of variceal
  bleed. (1a, A)

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EVL vs EST

• EVL is the endoscopic procedure of choice for
  esophageal varices in setting of acute bleed.
  (1b, A)
• EST is indicated only in setting of acute bleed
  in which EVL is not technically feasible. (5D)

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Procedure of endoscopic examination including
preparaion and techniquesession -4 (Endoscopy)

• Dr Pramod

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• Evidence Recommendation specific measure(DR
  GARG)
• Action Level of Evidence Grade Recomm.
• Maintain BP gt90 mm Hg 2a B
• Somatostatin stat 1a A
• and hourly infusion
• Inj. PP I 1a A
• Inj 3rd gen cephalosporin 1b A
• No Gastric lavage 2b B

If the cause of bleeding is uncertain
Comment Patients not in shock can be subjected
to endoscopy
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• Evidence Recommendation specific measure
• Action Level of Evidence Grade Recomm.
• Inj Erythromycin 2b B
• Propofol -individualize 5 D
• Double or large channel 5 D
• endoscope
• Posture left lateral 5 D
• fundus- right lateral 5 D
• Intubation for unconscious 5 D
• patient

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• Check List Before Endoscopy
• . Patient
• Vital signs,
• Two Intravenous lines
• Fluid resuscitation should be on
• Supplemental oxygen
• Consent
• . Endoscopy Theatre
• Check endoscope (air-water channel, suction,
  knobs etc.)
• Suction device
• Patient resuscitation cart
• Patient Monitor
• Accessories
• 3. Availability of alternate therapy
• Interventional Radiologist
• GI surgeon

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Sedation

• Routine use NOT to be recommended. (5D)
• May be indicated in selected situation with back
  up of intubation
• Drugs to be used
• Midazolam pethidine/Fortwin
• Propofol
• Propofol Midazolam
• (Based on user ease) (5D)
• Care in early encephalopathy or hemodynamic
  instability. (5D)

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Procedure of endoscopic treatment of acute
esophageal variceal bleed session -4 (Endoscopy)

• Dr G.Choudhuri

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Ideal EVL technique

• Using a multiband ligator
• Banding to be done starting from just above GE jn
  (5-10mm) in a sequential manner upto 5cm
• Tips In Acute variceal bleed
• First band to be applied on culprit vessel
• Try to catch the bleeding point
• Or just below the ooze
• Clean field of view using flush catheter
• Go into the stomach wait for Varix to collapse
  over it

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Summary of recommendations

• Endoscopic variceal ligation with multiband
  ligator is the treatment of choice for acute
  variceal bleeding(1 C)
• Upto 6 bands may be applied at each session(2A)
• Interval between sessions should be 2-4 weeks(2A)
• Injection sclerotherapy may be used for (1B A)
• control of actively bleeding esophageal varices
  if EVL is not available or difficult
• For 2nary prevention of bleed when varices have
  become small and difficult to band
• Intra-variceal injection with a free-hand
  technique is commonly used( 1C)
• There is considerable variation inchoice and
  volume of sclerosants (5D)

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EVL Induced ulcer bleed session -4 (Endoscopy)

• Gamal Shiha

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EVL ulcer bleed Diagnosis

• On endoscopy ulcer with
• Ooze or spurt or clot
• No evidence of other source of bleed
• 
  (5d)

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Treatment

• Indirect measures
• Correct coagulopathy
• PPI for 2 weeks
• Sucralfate
• (5D)
• Direct measures
• Banding, directly over the ulcer or below it
• Fibrin glue
• Cyanoacrylate injection
• Commentary to be made
• Role of HVPG/VASOACTIVES/FFP/TIPS/SURGERY/TYPE
  OR CLASSIFICATION OF ULCER
• PREDICTORS OF EVL ULCER BLEED NO EVIDENCE
• (5D)

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Role of repeat endoscopic therapy in acute
variceal bleeding session -4 (Endoscopy)

• Chunqing Zhang

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Repeat endoscopy

• 2nd attempt at UGIE is recommended (5D)
• Repeat endoscopy is needed
• To re evaluate the cause of bleed, is it same or
  something new
• To have one more attempt at endotherapy
• Repeat UGIE in this situation may need more
  expertise

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Can we scope recently placed bands?

• Yes, but need caution a more expertise. (5D)

71

• Is 2nd endoscopic treatment always needed or can
  be shifted to TIPS/PTVE/Surgery without it.
• This is being examined indirectly
• Probably poor prognostic marker as high HVPG may
  directly undergo TIPS (4)

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repeat endoscopy

• Carefully planned
• Risk stratification
• Rescue therapy plan to be initialized
• (5D)

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Role of balloon tamponade session -5(Rescue
therapy)

• Ahmed Helmy

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Current role

• Balloon tamponade should only be used in
  uncontrolled bleeding as a temporary bridge
  until definitive treatment can be instituted for
  a maximum of 12 h . (Class I, Level B).

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• How long should we wait for control
  ofbleeding?
• If Haemostasis is not achieved with temponade
  within 2 hours other therapeutic options should
  be tried. 5,D

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TIPS In acute esophageal variceal
bleedindication and results session -5(Rescue
therapy)

• Jin Wook Chung

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TIPS

• TIPS is indicated in patients in whom hemorrhage
  from esophageal varices cannot be controlled or
  who rebleed despite combined pharmacological and
  endoscopic therapy. (Grade of Recommendation B)
  (Evidence level 2a)
• Early TIPS placement (within 24 hours of
  hemorrhage) can be considered in high-risk
  patients (defined as those with an HVPGgt20 mmHg)
  with acute variceal hemorrhage. (Grade of
  Recommendation A or B) (Evidence level 1b or 2b)

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• In centers where the expertise is available,
  surgical shunt can be considered in Child A
  patients. The performance of both shunt surgery
  and TIPS are dependent on local expertise. (Grade
  of Recommendation A) (Evidence level 1b)
• In GOV2 / IGV1 bleeding, TIPS can be recommended
  if endoscopic cyanoacrylate injection therapy is
  not possible or after a single failure of
  endoscopic treatment. (Grade of Recommendation
  B) (Evidence level 1b)
• TIPS stent may cause technical difficulties in
  subsequent liver transplantation without
  significant influence on patient and graft
  survival. (Grade of Recommendation C) (Evidence
  level 3b)
• TIPS dysfunction is significantly reduced by
  using covered stents. (Grade of Recommendation A
  or B) (Evidence level 1b or 2b)

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Role of BRTO in acute variceal bleed session
-5(Rescue therapy)

• Jin wook CHUNG

80
BRTO

• BRTO is indicated in gastric varices with
  gastrorenal shunt when endoscopic cyanoacrylate
  injection is unavailable or failed. Before BRTO,
  the patient should achieve hemostasis using
  balloon tamponade / endoscopic therapy /
  pharmacologic measures. (Grade of Recommendation
  B) (Level of evidence 2b)
• BRTO of gastric varices shows high rate (gt90) of
  complete eradication of gastric varices and low
  rate (lt10) of gastric variceal recurrence during
  long-term follow-up. (Grade of Recommendation B)
  (Level of evidence 2b)
• BRTO might deteriorate liver function or
  aggravate hepatic encephalopathy. However, it
  induce or aggravate esophageal varices in
  substantial proportion of patients during
  long-term follow-up. (Grade of Recommendation B)
  (Level of evidence 2a)

81
NEED FURTHER DATA

• Role of BRTO in Child C patients
• Any stratification of patients for TIPS versus
  BRTO
• Need more data

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Newer therapies to control acute variceal bleed
session -5(Rescue therapy)

• C Z Li

83
NEWER THERAPY

• Endoesophageal stent therapy of acute variceal
  bleed is still in early stage and needs further
  evaluation
• (4
  C)

84

• Vapreotide is an alternative in control of acute
  variceal bleed
• 
  1B A

85
Infections in acute variceal bleeding and role of
antibioticsSession 6(special topics)

• Rungsun Rerknimitr, MD

86
Recommendation ADD

• Chances of developing infection on AVB is
  significant (1aA) and gram negative bacteria
  esp, E.coli are commonly detected in cultures
  (1a A)
• Various tubes (NG, CVP, ET, SB) insertion may
  cause infection (2bB) and colonized organisms in
  stomach and skin play role as etiology (2bB)
• Standard work up for infection when suspected
  include CBC, CXR, VA and blood culture (1bA)
• The preferred agents for prevention of infection
  in AVB is at least 5d of intravenousv3rd
  generation cephalosporin (1bA)

87
Prevention of hepatic ischemia assessment
management and reversibility Session 6(special
topics)

• Gamal Shiha

88
Conclusion
APASL Consensus on Acute Variceal Bleeding

• Ischemic hepatic injury can occur in upto 10
  cirrhotic patients WITH acute variceal bleed.
  This could lead to rises in serum total
  bilirubin and/or aminotransferases and LDH within
  24 h and it may adversely affect outcomes.
  Patients should be carefully observed even if
  hemorrhage from varices is controlled (3a).
• For diagnosis Daily Monitoring of ALT and S.
  Bilirubin and S.Creatinin in addition to serum
  LDH and ALT/LDH ratio (CHECK and GIVE UPPER
  LIMIT) when ischemic hepatic injury is suspected

89
Conclusion
APASL Consensus on Acute Variceal Bleeding

• Hepatic ischemic injury should be anticipated and
  prevented in high risk groups of patients with
  bleeding varices (5).
• There is a need for prospective studies to
  investigate the prevalence, severity, and
  treatment of hepatic ischemia in cirrhotic
  patients with variceal bleeding (5).

90
High risk groups of hepatic ischemia in patients
with variceal bleeding
APASL Consensus on Acute Variceal Bleeding
High risk patients

• Patients with severe haematemesis and Melena
• Bleeding leading to significant hypotension
  and/or shock.
• Recurrent bouts of bleeding at home, during
  transfer, at the causality department, in the
  ward, and before or during emergency endoscopy
  even if there is no shock.

91
APASL Consensus on Acute Variceal Bleeding

• Repeated vomiting of fresh bright red blood not
  altered by the acidity of the stomach.
• Rebleeding in a known patient with history of
  variceal bleeding.
• Significant drop of Hemoglobin and more
  specifically Hct values.

92
High risk groups of hepatic ischemia in patients
with variceal bleeding
APASL Consensus on Acute Variceal Bleeding

• Patients with obstruction to hepatic blood flow
• Portal vein thrombosis.
• Veno-occlusive disease.
• Patients with decompansated cirrhosis even if
  hypotension is not severe.
• - Elderly patients.
• - Patients with Diabetes Mellitus.
• - Cirrhotic patients with HCC.

93
Prevention
APASL Consensus on Acute Variceal Bleeding
Prevention and treatment of ischemic hepatic
injury

• Resuscitation and adequate correction of
  hypovalaemia, hypotension and shock.
• Correction of severe anaemia by blood transfusion
  when necessary.
• Rapid control of active bleeding by endoscopy.
• prophylactic antibiotics to guard against
  sepsis.
• Treatment No definite therapy has been found for
  the treatment of ischemic hepatic injury,but n
  acetylcysteine may be tried(5d)

94
Acute variceal bleeding in patients with liver
failure Session 6(special topics)

• Ji Dong Jia

95
Recommendations

• Patients with cirrhosis and liver failure have
  high propensity for bleeding from
  gastroesophageal varices (5D)
• Attempt at endoscopy procedure to control
  variceal bleed may be done under endotracheal
  intubation/extra caution (5D)
• Coagulopathy should be corrected with FFPand
  platelets.
• Role of FACTOR rV11a in this setting needs
  evaluation (5D)

96
Role of HVPG in management of acute variceal
bleed Session 6(special topics)

• Dr Ashish

97
Consensus Statements

• Cirrhotic patients who experience esophageal
  variceal bleeding have an HVPG of 12 mmHg (Level
  1a)
• Portal pressure is independent predictor of
  outcome(1a)
• HVPG of 20mmHg or above predicts failure to
  control bleed in response to first line therapy

98
Consensus Statements

• HVPG measurement lt24 hrs may be useful in all
  patients of AVB, since it gives important
  prognostic information and also helps in making
  treatment decision. (2b, B)
• HVPG in gastric varicesstatement to be written
  in commentary.
• Criteria regarding level of response to HVPG to
  vasoactive drugs needs to be established

99
Consensus Statements

• Repeat HVPG measurement is helpful in identifying
  patients who do not respond to vasoactive drugs,
  however, more data is needed to recommend a
  repeat measurement of HVPG (2b, B)

100
FUTUREIssues Answered Unansweredto be written
in commentary

• Answered
• Is there any role of portal pressure monitoring
  in setting of acute variceal bleeding?
• Should pharmacotherapy be HVPG guided?
• How often should HVPG be repeated in acute
  setting?
• Can HVPG help in prognosis?
• Unanswered
• Procedural differences in HVPG measurement in
  setting of acute variceal bleeding and routine
  HVPG measurement?
• Can HVPG catheter be left in situ for extended
  periods of time?
• Safety of HVPG in acute setting?
• How HVPG results vary in patients already on
  pharmacologic therapy
• If HVPG decreases to lt12 mm Hg do we still need
  endoscopic therapy?

101
Diagnosis and endoscopic tratment of gastric
variceal bleedsession 6 special topics

• Dr B C sharma

102
Acute Gastric Variceal BleedingConsensus
Statements

• Diagnosis
• In patients with acute bleeding from gastric
  varices, endoscopic variceal obturation using
  tissue adhesives such as cyanoacrylate is
  treatment of choice (1b,A).
• Regarding role of vasoactive therapy, there is
  rationale to use combination therapy despite lack
  of specific data at present (5D)
• In patients with acute bleeding from GOV1 type of
  varices, treatment should be similar to that of
  esophageal varices or cyanoacrylate injection
  (2b,B).
• TIPS to be considered in patients with
  uncontrolled bleeding from gastric varices or if
  bleeding recurs despite combined pharmacological
  and endoscopic treatment (2b,B).
• BRTO is good alternative to TIPS in patients with
  gastrorenal/gastrocaval shunt after achieving
  initial hemostasis (2b,B)

103
Acute Gastric Variceal BleedingEndoscopic
Treatment

• A second attempt at endoscopic therapy may be
  tried if other rescue therapies like TIPS/BRTO
  are not available or are contraindicated (5d)
• In the commentary how to diagnose Gastric
  Varices should be mentioned

104
Acute Gastric Variceal BleedingAlgorithm
Bleeding Gastric Varix
Resuscitation
GOV1
GOV2, IGV1, IGV2
Tissue Adhesives or Treat as Esophageal Varices
Tissue Adhesives (2nd Line Band Ligation,
Thrombin)
Control of Bleeding
No
Yes
Balloon Tamponade
Secondary Prophylaxis
Splenectomy or Embolization in Segmental
Portal Hypertension
Shunt Surgery Compensated Cirrhosis TIPS or BRTO
Not Feasible
BRTO
Salvage TIPS
105
Acute variceal bleed in NCPH (medical aspect)
Yusuf Bayraktarsession 6 special topics
106
How does acute variceal bleeding differ in
non-cirrhotic portal hypertension from cirrhotic
portal hypertension?

• Absence of ascites, jaundice and hepatic
  encephalopathy and presence of large splenomegaly
  are the clinical clues in differentiating NCPH
  from CPH (5, D).
• Natural history of acute variceal bleed in NCPH
  has not been well studied, but mortality is low
  (4C)

107
Diagnosis Treatment modalities

• Definitions and time frames for acute variceal
  bleed as for cirrhotics can be adapted (5D)
• First line treatment options are essentially same
  as in cirrhotics (5D)
• Gastric varices are more common and may be
  refractory to obturation by tissue adhesive (5D)
• Coagulaopathy is generally not a feature, and so,
  correction is not required (5D)
• Rescue therapies remain same as in cirrhotics
  (5D)
• Antibiotics are generally not needed, unless ANClt
  1000 (5D)

108
Dr BaijalNCPH radiology

• session 6 special topics

109
D (Case Report) Level of evidence
-5 Recommendation -D
A,B,C (Case series) Level of evidence
-4 Recommendation -C
110
CHOICE OF PROCEDURE

• Factors influencing choice of procedure
• (1) Etiological considerations
• (2) Anatomical considerations
• (3) Clinical status of patient
• (4) Affordability and available expertise

5D
111
TIPS complications

• No published data are available on the
  rate of complications of TIPS in patients with
  NCPF however, owing to the good hepatic
  functions, it might be logical to conclude that
  such complications would be uncommon in NCPF.

112
Radiological treatment options

• Though no randomized control trials have been
  conducted to investigate the potential of this
  technique, case reports and case series reports
  suggest efficacy for controlling variceal
  bleeding.
• 
  (4,C)

113

What is the frequency, site, diagnosis of
ectopic variceal bleeding? How to treatectopic
variceal bleeds?

• Yogesh Chawla
• session 6 special
  topics

114
What is the frequency, site diagnosis of
ectopic variceal bleeding

• Bleeding ectopic varices are a rare cause of
  variceal bleeding and are common in non
  cirrhotics 3bC
• Ectopic varices occur in anorectum,
  antroduodenal,, duodenum, SI, colon, and
  peristomal
  3bC
• Bleeding is more frequent in peristomal varices
• Endoscopy can diagnose most of the cases but in
  inaccessible site, RBC scan would identify the
  site of bleed and confirmed by angiography or CT
  angiography

3bC
115
How to treat ectopic variceal bleeds

• Pharmcotherapy and endotherapy should be the
  first line of therapy if bleeding ectopic varix
  is accessible, but in inaccessible cases, TIPS or
  PTVO should be done in patients with patent
  portal vein in cirrhosis and NCPH
• Duodenal variceal bleeding inaccessible by
  endoscopy can also have an option of BRTO if
  vascular anatomy permits.

4C
4C
116
Dr PeushSurgical treatment of acute varieal
bleed in NCPHSESSION 7 NCPH
117
Emergency surgery NCPH (add level of evidence)

• Patients with failed first line therapy for
  variceal bleeding should be considered for
  surgery
• Portal decompressive procedures are better than
  non-shunt procedures
• Non-shunt procedures in patients who do not have
  shuntable veins

118
Dr BaijalRadiological treatment of acute
variceal bleed in NCPHSESSION -7 NCPH
119
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120
Radiological treatment options

• Though no randomized control trials have been
  conducted to investigate the potential of this
  technique in children, case reports and case
  series reports suggest efficacy for controlling
  variceal bleeding.
• 
  (4,C)

121
Dr YachhaPeadiatric perspective of acute
variceal bleed(medical treatment)
122
Statement

• Definition of child age upto 18 yrs
• Majority of UGI bleed in children is variceal in
  origin (2aB)
• Etiology of AVB in children varies in dt
  geographical regions (west cirrhosis, East
  EHPVO)

123

• Diagnosis and management is broadly similar to
  that in adults (5D)
• Band ligation is preferred over EST for AVB. EST
  is technically feasible in younger children and
  those with smaller varices.
• Commentary on transfusion/fluid resuscitation to
  be submitted
• Dosage and safety profile of octreotide in
  children has been established. However, for
  terli/somtostatin the dose and safety needs to be
  established (5D)
• Since, the etiological profile of AVB in children
  is different to that in adults, the threshold for
  surgery as first line rescue therapy is low (5D)

124
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