When variceal bleeding is suspected, lab tests should include a complete blood count, comprehensive chemistry panel, coagulation studies, blood cultures, and troponin and lactate levels to assess the extent of the hemorrhage and its sequelae. A hemoglobin of less than 10 g/dL has been associated with a poor prognosis.³ The most important lab test, however, is a type and crossmatch for 2-6 units of blood, particularly in patients with large-volume hematemesis or other evidence of massive hemorrhage.3 An ECG to rule out related cardiac ischemia is worthwhile. One study found that nearly 50% of patients sent to the ICU for GI hemorrhage had laboratory evidence of cardiac damage.¹⁴

Gastric lavage via nasogastric tube traditionally has been used to assess if the bleeding is proximal to the duodenum and if the bleeding is active (as shown by clearing aspirate on repeated lavage). Although nasogastric aspiration has not been shown to improve outcomes, it has been linked to improved visual conditions for endoscopy.^6,15,16 Endoscopic evaluation is the mainstay of diagnosis and treatment for evaluation of upper GI hemorrhage in general and variceal hemorrhage in particular. This should reinforce the importance of early consultation with GI specialists.

Treatment

As always, in critical conditions, the emergency physician should follow the airway, breathing, circulation sequence. Accordingly, the first priority in the management of variceal bleeding is to ensure a working airway. Early intubation should be considered for a number of reasons, including maintaining an airway with depressed mental status caused by hepatic encephalopathy, decreasing aspiration risk and hypoxia, and facilitating optimal endoscopy.¹²

Once the airway and breathing have been addressed, the circulation status will require a number of interventions. These patients should have intravenous access with two large-bore catheters or a central line to facilitate resuscitation. Volume resuscitation can begin with crystalloid solutions, but should include blood products in the case of active hemorrhage. Transfusion should be aimed at maintaining both hemoglobin at approximately 8 g/dL and hemodynamic stability.¹⁷

Although there is no recommended dosage of fresh frozen plasma or platelets, both should be considered in patients with marked coagulopathy or thrombocytopenia. Care should be taken while giving blood products, as overtransfusion can lead to worsening portal hypertension, and fresh frozen plasma and platelets have not been shown reliably to correct coagulopathy in these scenarios.⁷

A number of pharmacologic interventions should be instituted for patients with variceal hemorrhage. Proton pump inhibitors (PPIs) have been prescribed for patients with suspected gastroduodenal ulcer disease, and should be considered in variceal hemorrhage, as well. Acid suppressive therapy is theorized to improve the stability of clot, and infusion of omeprazole has been shown to reduce risk of recurrent bleeding and need for emergent surgery in all cases of upper GI hemorrhage.¹¹ Because it is difficult initially to differentiate esophageal variceal bleeding from ulcerative causes, all patients with upper GI hemorrhage should receive PPI infusion. Omeprazole and esomeprazole dosages are 80 mg IV bolus followed by 8 mg/hour IV infusion.¹¹