Vasoactive drugs also have been shown to benefit these patients. Terlipressin, a vasopressin analog, has been shown to improve prognosis in variceal bleeding, preserving renal function and controlling hemorrhage. Unfortunately, it is not available in the United States. Octreotide has a demonstrated benefit for controlling hemorrhage, but it has not been shown to improve mortality on its own.¹² It does, however, significantly decrease early rebleeding when used in combination with sclerotherapy, and it has found wide acceptance in the United States. Octreotide is given in a 50 mcg bolus followed by an infusion of 25-50 mcg/hour for 2-5 days.⁴

Antibiotic therapy decreases the release of endotoxins, which helps reverse systemic vasodilation, ameliorates worsening liver function and subsequent coagulopathy, and prevents early rebleeding.¹⁸ Most antibiotic regimens have been directed against gram-negative bacilli and have included drugs such as norfloxacin or ciprofloxacin. Ceftriaxone has been shown to be superior to quinolones and is recommended for 5-7 days of administration following a variceal hemorrhage.⁶

Another antibiotic, erythromycin, has been used primarily for its promotility effects, and has been shown to improve the quality of endoscopy, decrease time required to perform the endoscopy, and decrease the need for second-look procedures.^19,20 Metoclopramide has also been used for this purpose, but erythromycin is likely more cost effective.²¹

Although these pharmacologic interventions are important, endoscopy remains the definitive treatment of choice for variceal hemorrhage. The details of endoscopic technique fall under the purview of gastroenterology, but it will be useful to examine general issues of timing here. Endoscopic band ligation (EBL) and sclerotherapy are the treatment modalities most frequently used, though EBL has been shown generally superior.²² For hemodynamically stable patients, early endoscopy has not been shown to improve outcomes over later endoscopic intervention.²³ In stable patients, no significant differences have been shown between endoscopy within 6 hours of the bleeding event and within 24 hours.²⁴ Early GI consultation remains beneficial for coordination of therapy, and potentially unstable patients should be seen urgently by GI specialists.

Some therapies that traditionally have been thought of as last-ditch rescue therapies, such as transjugular intrahepatic portosystemic shunt (TIPS) and portacaval shunt, are beginning to be used more widely. Recently, controlled trials have found that early TIPS or portacaval shunt significantly reduces treatment failure and mortality, particularly in patients at high risk for rebleeding.²⁵ In one prospective trial, portacaval shunt procedures outperformed endoscopy in terms of prevention of rebleeding, prevention of encephalopathy, and long-term mortality.²⁶ As evidence mounts of the safety and efficacy of TIPS in patients with less-severe liver failure, physicians treating variceal bleeding may begin considering it earlier in the course of treatment.