One treatment modality that likely will remain a salvage therapy is balloon tamponade. A rescue therapy for actively exsanguinating patients, the Sengstaken-Blakemore or Minnesota tube, when inflated within the esophagus, can control variceal bleeding in up to 90% of cases. The complication rate, however, approaches 30%, including aspiration pneumonia, airway obstruction, esophageal perforation, or mucosal injury. It is therefore recommended for use only by experienced clinicians in emergent situations, and after endotracheal intubation. Rebleeding following balloon deflation occurs in approximately 50% of cases.⁷

Recombinant factor VIIa has been studied as an adjunct therapy but so far has not shown sufficient utility to warrant routine use. Intended to improve coagulopathy during active bleeding, factor VIIa has not been shown to control bleeding or prevent rebleeding in randomized, controlled trials. There does appear to be an improvement in 6-week mortality. Given the cost involved and lack of firm evidence base, this drug should be used only as salvage therapy.⁶

Conclusion

Despite significant improvement in mortality in the last 25 years, variceal hemorrhage remains a deadly condition that can be difficult to manage in the emergency department setting. Keys to management include recognizing the poor prognosis and beginning treatment promptly, knowing the key pharmacologic interventions and coordinating care early with GI or surgical services as appropriate. One center found that prophylactic antibiotics were given to only 25% of variceal hemorrhage patients, while beta-blockers were given to only 24% of those with no contraindication, illustrating the need for improved communication and education.27 Informed emergency physicians are in an excellent position to make a difference in the care of these patients.

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