Gastrointestinal/Abdominal 1: Esophageal Varices Portal
Clinical Consideration
If the patient has an upper GI bleed and there is evidence of severe liver disease, variceal bleeding is the most likely cause for the bleeding. If the patient is bleeding massively, approach the problem aggressively.
Management
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Airway protection is needed. Prepare to keep the airway clear with suction. RSI with orotracheal intubation may be necessary as soon as IVs are established. (Vol III—AIR1 Rapid Sequence Intubation)
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Establish 2 large-gauge IV lines. Begin volume replacement starting with a 1 to 2 L bolus NS IV in adults. PEDS: Use 10 to 20 mL/kg in children. Begin blood replacement early to avoid hemodilution and further hypocoagulopathy.
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Establish central venous access (Vol II—CIRC SKILLS 2 Central Venous Access) for monitoring CVP (Vol II—CIRC SKILLS 2 Central Venous Pressure Measurement).
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Insert a large-bore orogastric tube and attempt to empty the stomach of blood. Lavage the stomach with warm tap water. If the returns become clear, continue the lavage intermittently to determine if the bleeding is continuing. Also note if blood regurgitates around the gastric tube.
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If the patient demonstrates a hypocoagulable state (bleeding from needle puncture sites), administer vitamin K 10 to 15 mg IM. This takes many hours for effects to show. Document hypocoagulable state with blood tests. Administer fresh frozen plasma for rapid control.
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Administer a vasopressin drip (20 units in 200 mL NS) at 0.25 to 0.5 units/min (150 to 300 cc/h) to reduce blood flow in the splanchnic bed. Offset the potential coronary artery constriction associated with vasopressin with a nitroglycerin drip (25 mg in 250 mL NS) at 10 to 20 μg/min.
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Alternatively, administer octreotide, a synthetic growth hormone (Sandostatin) with splanchnic blood flow effects, at 50 μg IV. Octreotide does not cause coronary artery constriction.
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Obtain an ECG to examine for signs of ischemia.
- If bleeding continues:
- Remove the orogastric tube and replace it with a Minnesota tube.
- Insert the Minnesota tube through a bite block.
- Inflate the gastric balloon with 50 cc of air; x-ray to be certain that the gastric balloon is in the stomach and not the esophagus.
- Then inflate the gastric balloon to a volume of 350 cc.
- Pull the Minnesota tube through the bite block at a tension of about 2 lbs (the weight of a liter bag of NS). Secure it there with the sponge block that accompanies the tube.
- Attach suction to the esophageal and gastric ports.
- Irrigate the stomach and observe for continued bleeding from either port. If bleeding continues, fill the esophageal balloon to a pressure of 40 to 50 torr and observe again for bleeding.
- The Minnesota tube stops the esophageal bleeding about 60% to 70% of the time. If it does not, the only alternative treatment is emergency surgery or emergency esophagoscopy and sclerosis.
