Q1: Answer: D
Objective: Understand the role of the restrictive transfusion strategy during patient stabilization and resuscitation as the initial step in the management of a variceal bleed.
Discussion: The initial therapy for acute variceal hemorrhage is resuscitation in an intensive care unit. Blood volume restitution should be undertaken promptly but with caution, with the goals of maintaining hemodynamic stability and hemoglobin around 7–8 g/dL.
Over-transfusion or volume overexpansion can precipitate variceal re-bleeding. A randomized clinical trial found that a restrictive transfusion strategy (transfusion when the hemoglobin fell below 7 g/dL) in patients with cirrhosis significantly improved survival. Endoscopic evaluation with potential variceal band ligation is appropriate only after initial resuscitation and stabilization of the patient.
Placement of a Blakemore tube and TIPS are not first-line therapy for this patient with Childs class A cirrhosis, and could be considered for recurrent bleeding that fails endoscopic therapy.
Endoscopic variceal ligation is more effective than sclerotherapy and is associated with fewer side effects. However, in patients for whom endoscopic variceal ligation is not feasible, sclerotherapy is a reasonable alternative.
References
1. Garcia-Tsao G., Sanyal A.J., Grace N.D., Carey W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46(3):922-38.
2. Garcia-Tsao G., Bosch J.. Management of varices and variceal hemorrhage in cirrhosis. N Engl J Med. 2010;362(9):823-32.
3. Villanueva C., Colomo A., Bosch A., et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013;368(1):11-21.
4. Villanueva C., Piqueras M., Aracil C., et al. A randomized controlled trial comparing ligation and sclerotherapy as emergency endoscopic treatment added to somatostatin in acute variceal bleeding. J Hepatol. 2006;45(4):560-7.
