Refractory Variceal Bleeding Management
Management options for refractory bleeding include balloon tamponade or Danis Ella stent (bridging therapies), interventional radiology-guided TIPS (IR-TIPS)/balloon-occluded retrograde transvenous obliteration and surgery.
Essential considerations involve terlipressin/octreotide, ceftriaxone, metoclopramide (erythromycin), maintaining mean arterial pressure at ~65 mmHg, securing the airway for HE or continuous bleeding, monitoring ECG and electrolytes, conducting a CT scan for anatomy, hepatocellular carcinoma (HCC) and portal vein thrombosis; involving insulin resistance and maintaining hemoglobin at 7-8 g/dL.
No FFPS is recommended, and TEG-based correction may offer better outcomes. Risk factors for re-bleeding include MELD >17, HVPG >20 and PPG >21.
Post-endoscopic variceal ligation (EVL) monitoring is crucial.
The use of self-expanding metal stents (SEMS) is preferred if available and affordable, with salvage TIPS considered superior to surgery for cirrhosis.
Conversely, surgery is favored over TIPS for extrahepatic portal vein obstruction
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