Oesophageal Varices – GCCNurseJobs.com Clinical Guide

Portal Hypertension & Varices

HVPG Thresholds

Normal: <5 mmHg
Clinically significant portal HTN: ≥10 mmHg
Variceal bleed risk: HVPG >12 mmHg
Varices form to decompress portal circulation

Mortality

Variceal haemorrhage carries 15–20% mortality per episode. Risk of re-bleed within 5 days = 30–40%. Early definitive management is critical.

Primary & Secondary Prophylaxis

Primary Prophylaxis (prevent first bleed)

Non-selective beta-blocker (NSBB): propranolol or carvedilol
OR Endoscopic Variceal Ligation (EVL)
Not both together routinely

Secondary Prophylaxis (prevent re-bleed)

NSBB + EVL (combination preferred)
TIPSS for those who re-bleed on combination
Lifelong monitoring required

Acute Variceal Bleed — Clinical Features & Resuscitation

EMERGENCY — Immediate Actions

ABC — airway protection (GCS <8 → intubate before endoscopy)
2 large-bore IV cannulas (16G or larger)
Bloods: FBC, U&E, coag, crossmatch 6 units
Target Hb 70–80 g/L (RESTRICTIVE transfusion reduces re-bleed)
Avoid over-transfusion — increases portal pressure
FFP/platelets if coagulopathy significant

Terlipressin — Give BEFORE Endoscopy

Vasoconstrictor reduces portal pressure and splanchnic blood flow. Give immediately on clinical suspicion (before endoscopy confirmation). 2 mg IV 4-hourly, reduce to 1 mg after haemostasis achieved.

Prophylactic Antibiotics

Ceftriaxone 1g IV daily (or norfloxacin 400mg BD oral) for 5–7 days. Reduces SBP risk and re-bleeding. Mandatory in all patients with acute variceal haemorrhage.

Endoscopic Management

EVL (Endoscopic Variceal Ligation) — First-Line

Endoscopy within 12–24 hours of admission (after haemodynamic stabilisation). EVL (band ligation) is first-line endoscopic therapy. Superior to sclerotherapy. Banding sessions repeated every 2–4 weeks until varices obliterated.

Sengstaken-Blakemore Tube — Temporising Only

Only if EVL not immediately available or massive uncontrolled bleed
Maximum inflation time: 24 hours (risk of oesophageal necrosis)
Must intubate patient first (aspiration risk)
Bridge to definitive therapy (EVL/TIPSS)
Nursing: hourly pressure checks, suction airway, document balloon pressures

TIPSS (Transjugular Intrahepatic Portosystemic Shunt)

For refractory variceal bleeding not controlled by endoscopy + pharmacotherapy. Creates intrahepatic shunt between portal and hepatic veins to decompress portal circulation. Risk of hepatic encephalopathy post-procedure (increased ammonia). Monitor neurological status post-TIPSS.

Hepatic Encephalopathy

Common complication of variceal bleed (blood in gut → ammonia). Graded I–IV. Lactulose (2–3 loose stools/day target) and rifaximin are treatments. Monitor orientation, asterixis, GCS. Avoid sedatives.

Spontaneous Bacterial Peritonitis (SBP)

Risk elevated post-variceal bleed. Prophylactic antibiotics reduce SBP incidence. Diagnose by ascitic tap — WCC >250 PMN. Treat with cefotaxime IV. Mortality high without treatment.

GCC Liver Disease Context

HBV & HCV — Primary Causes (Not Alcohol)

In Islamic GCC countries, alcohol consumption is restricted by law and religion, so alcohol-related cirrhosis is far less common than in Western settings. The main causes of cirrhosis/portal hypertension are Hepatitis B and Hepatitis C infection, followed by NAFLD (non-alcoholic fatty liver disease).

NAFLD/NASH Cirrhosis Rising Rapidly

GCC has among the world's highest rates of obesity (40–50% in adults), T2DM (20–30%), and metabolic syndrome. NAFLD is now the fastest-growing cause of cirrhosis. Expect increasing variceal complications from NAFLD-related portal hypertension in coming decades.

HBV Screening at GCC Recruitment

All migrant workers entering GCC countries undergo mandatory HBV (and HCV) screening as part of pre-employment medical examination. HBV vaccination is part of the national immunisation schedule. GCC has substantially reduced HBV prevalence through vaccination programmes.

NEJM TRIGGER trial evidence supports restrictive transfusion (target Hb 70–80 g/L) in variceal haemorrhage. Over-transfusion increases portal pressure and re-bleed risk. GCC hospitals follow international guidelines; blood products readily available in major centres.

Living-donor liver transplantation is available in major centres (KFSH&RC Riyadh, HMC Doha, Cleveland Clinic Abu Dhabi). Religious scholars have approved living-donor transplantation. Deceased-donor programmes are limited due to lower rates of organ donation consent.

Key Exam Points

Variceal bleed mortality = 15–20% per episode
Terlipressin given BEFORE endoscopy on clinical suspicion
Target Hb 70–80 g/L (restrictive — over-transfusion increases re-bleed)
Prophylactic antibiotics mandatory (ceftriaxone/norfloxacin) for 5–7 days
EVL = first-line endoscopic treatment
Sengstaken-Blakemore = temporising only, max 24h, intubate first
TIPSS for refractory cases
GCC: main causes = HBV/HCV (not alcohol); NAFLD rising

Practice MCQs

1. A patient with known cirrhosis presents with massive haematemesis. Initial blood transfusion target Hb should be:

2. When should terlipressin be given in suspected variceal haemorrhage?

3. The Sengstaken-Blakemore tube should be left inflated for a maximum of:

4. In GCC countries, the most common cause of portal hypertension and oesophageal varices is: