Gastrointestinal Bleeding – Part 6
The development of varices in the stomach or esophagus can be a life-threatening problem. Because of the large volume of blood that flows through them, their thin walls, and inability of cirrhotic patients to make adequate clotting factors, varices can bleed and do bleed massive amounts, with the patient often vomiting most of it. It is not uncommon for patients to bleed to death from a ruptured varix.
In bleeding varices, emergent intervention is required. The patient should be given intravenous saline solution
until packed red blood cells, fresh frozen plasma, and platelets are available. In addition, there are several mechanical maneuvers and several pharmacological maneuvers to try to stop the bleeding.
Most physicians recommend immediately starting the patient on the drug octreotide. In addition, some advocate starting the patient on beta-blockers or the powerful vasoconstriction drug vasopressin.
An gastroenterologist experienced in treating variceal bleeds should be emergently consulted. Via endoscopy, the bleeding varix can be localized with an attempt made at injecting solution into the bleed to stop it, such as epinephrine. This is termed sclerosis. Alternately, the base of the varix can be grasped and mechanically choked off by literally placing a rubber band around it – a process called banding.
If it appears that the patient will bleed to death (aka exsanguination) before the gastroenterologist arrives, most physicians recommend attempting placement of a Sengstaken-Blakemore tube. This tube is similar to a nasogastric tube that is inserted through the nose, except that it has two inflatable balloons – one located at the tip and one located along the shaft. It is inserted through the nose or mouth until the tip is well within the stomach. The distal balloon is then inflated with water and the tube is “pulled back out” until the inflated balloon comes up against the stomach wall and the inserter feels resistance. The midshaft or esophageal balloon is then inflated. The hope is that the pressure of the inflated balloons on the stomach and esophageal wall will literally tamp down (tamponade) the bleeding site.
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