Esophageal Varices usually develop when Chronic liver disease patients have HVPG >10 mmHg.The presence of HVPG > 12 mmHg is a risk factor for variceal bleeding.
Reduction in HVPG to less than 12 mmHg or by ≥ 20% from baseline reduces the risk of initial bleeding, and other complications of portal hypertension (ascites, encephalopathy)
After an initial resuscitation prepare the patient for emergency endoscopy. If the patient is actively bleeding elective intubation may prevent aspiration before endoscopy .
The patient may be better managed in ICU . Stop Beta-blockers
Management
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o Insert 2 large bore (18/16G) IV canula
o IV fluids maintain systolic BP >100MMHg)
o Blood transfusion ->7-8gm/dl. Do not over transfuse.
o FFP to keep INR <2.5
o PPI 20-40 mg IV BD &Plan UGI endoscopy.
o Splanchnic vasoconstrictors any one of the following
1. IV Terlapressin:1-2 mg every 4hrly for 48hrs then 1mg every 6hrly
2. IV octreotide :50microgram bolus followed by 50 microgram /hr infusion
3. IV Somatostatin:250 microgram BOLUS followed by 250microgram /hr infusion
Antibiotics: Injection ceftriaxone 1gm BD for 7 days
SB tube as a bridge therapy for 24 hrs
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