Complications of liver disease: Esophageal Varices

What are the goals of treatment of esophageal varicices bleeds?

1. Correct hypovolemia (due to blood loss) and prevent re-bleed 2. Maintain Blood Pressure. 3. Prevent Hypovolemic shock and infection. 4. Prevent hepatic encephalopathy

Which of the following is *NOT* used as secondary prophylaxis for esophageal varicies? A. Metoprolol. B. Propanolol. B. Nadolol. C. Carvedilol.

A. Metoprolol. A non-specific beta-blocker (not metoprolol) is preferred in order to decrease cardiac output (via block of beta 1) *AND* splenic blood flow (via block of beta 2)

When is Trans-jugular intra-hepatic porto-systemic shunt (TIPS) procedure indicated in a patient with esophageal varices?

After treatment failure with standard therapy (nadolol). OR. for patients with Child class C or hepatic venous pressure gradient > 20 mm Hg.

What is the incidence of infection with variceal bleeds? A. 60-80%. B. 35-65%. C. 20-40%

B. 35-65%. For every 1 hours in delay of antibiotics, mortality increases by 8%. Treatment duration is 7 days.

In which of the following patient populations is secondary prophylaxis with beta blockers indicated (select all that apply)? A. Early Cirrhosis. B. Decompensated Cirrhosis. C. End-stage Cirrhosis.

B. Decompensated Cirrhosis. In patients with end-stage cirrhosis, beta blockers *reduce* survival due to negative impact of cardiac reserve, resulting in decrease profusion. Can cause hepatorenal syndrome.

Which of the following is *not commonly* used in acute treatment of an esophageal varices bleed? A. Octretide. B. Variceal ligation. C. Proton Pump Inhibitors. D. Dobutamine. E. Ceftriaxone

D. Dobutamine. Dobutamine can be used but is not often needed since patients has sufficient cardiac function.

Which of the following is NOT a contraindication for treatment with beta blockers. A. Refractory ascities. B. sepsis. C. Hepatorenal syndrome. D. Decompensated Cirrhosis

D.Decompensated Cirrhosis. Decompensated Cirrhosis is not a contraindication. Beta blockers improve survival by reducing variceal bleeding and gut bacteria translocation.

True or False: all patients with liver failure including those with early cirrhosis should be treated with beta blockers for prevention of esophageal bleeding.

False: Beta blockers have no effect on survival in patients with early cirrhosis And may *increase* adverse events.

True or False: in secondary prophylaxis for esophageal varicies bleeds, either nadolol or variceal ligation should used but not incombination

False: Using both has shown to reduce mortality.

which of the following is *not* a risk factor for day 5 treatment failure for esophageal varicies? A. Child-Turcotte-Pugh score. B. Units transferred. C. Increased ALT. D. Portal vein thrombosis

Increase ALT but not AST is a predictor for treatment failure. Class C has a greater risk of treatment failure compared to Class A.

What is the appropriate dose of octreotide for treatment of an esophageal varicies bleed?

Loading dose of: 50-100 mcg. Continuous Infusion of: 25-50 mcg/hour.

what are the potential risks of indiscriminate treatment with blood products in patients with an active bleeding with esophageal varicies?

Risk of continued bleeding and re-bleeding. Transfusion of FFP and platelets can increase portal pressure worsen bleeding. Remember patients with liver failure have increase PT, decreased clotting factors, and low platelet counts.

True or False: Administration of antibiotics in variceal bleeds decreases mortality and reduces incidence of re-bleed

True.

What is the pathophysiology of esophageal varicies?

Varicose veins in the esophagus as a result of portal hypertension and increased pressure in the coronary vein. The vessels can leak blood or even rupture, causing life-threatening bleeding.

Besides reduction in incidence of re-bleeds, what is one other benefit of secondary prophylaxis of esophageal varicies using beta blockers?

reduces risk of SBP (infection) and improved survival.