Actively Bleeding Esophageal Varices When TIPS Is Unavailable
62-year-old man with Child-Pugh B cirrhosis, known large esophageal varices, and prior banding presents with hematemesis. He takes nadolol but admits missing doses. Heart rate 112/min, blood pressure 98/60 mmHg, hemoglobin 7.8 g/dL, platelets 78,000/uL, INR 1.6. He is alert but anxious. Endoscopy reveals actively spurting variceal bleeding at 30 cm from the incisors; no gastric varices are seen. The unit has a banding kit, sclerotherapy needles, octreotide, ceftriaxone, and a Blakemore tube. The on-call intensivist is in the ICU, and the interventional radiology suite is closed until morning.
1. What resuscitation and pharmacologic steps do you take before and during endoscopy?
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Prioritize airway, breathing, and circulation. Give oxygen, establish two large-bore IVs, send type and crossmatch, and resuscitate with packed red blood cells and crystalloid to a target hemoglobin of about 7-8 g/dL; overtransfusion can raise portal pressure and worsen bleeding. Check platelets and coagulation, but do not routinely correct INR 1.6 with FFP solely for the number.
Start a vasoactive agent (octreotide 50 mcg IV bolus then 50 mcg/h) and ceftriaxone 1 g IV daily before endoscopy. Consider endotracheal intubation for airway protection if he is encephalopathic, vomiting, or cannot protect his airway. Alert the ICU and blood bank. Do not delay antibiotics or vasoactive therapy for endoscopy.
2. Endoscopy shows active spurting from an esophageal varix. What is your endoscopic approach, and what do you do if banding fails?
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For esophageal variceal bleeding, band ligation is first-line; sclerotherapy is reserved for cases where banding cannot be performed. Load the banding device, identify the bleeding point, and deploy bands starting at or just below the bleeding site, then proceed proximally. Avoid banding in the esophagus too high near the cricopharyngeus. If active spurting obscures the view, suction and lavage, stabilize the patient, and band the likely source.
If banding fails or the airway is threatened, place a Blakemore tube as a temporizing bridge and arrange urgent rescue TIPS; interventional radiology is unavailable until morning, so escalate to transfer or on-call IR. Sclerotherapy is a fallback only if banding cannot be used. Document the number and location of bands.
3. Outline post-procedure management and secondary prophylaxis.
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Admit to ICU or monitored bed. Continue octreotide for 2-5 days and ceftriaxone for 5-7 days per local protocol. Transfuse restrictively and monitor for rebleeding, infection, and hepatic decompensation. Do not start a nonselective beta-blocker until bleeding is controlled and hemodynamics are stable; then titrate nadolol.
Arrange repeat EGD in 2-4 weeks for additional banding until varices are eradicated, and discuss early TIPS if he rebleeds or is high risk. Counsel abstinence from alcohol if relevant, and document the plan for variceal surveillance. If he develops recurrent hematemesis or hypotension, activate the massive transfusion and rescue TIPS pathways.