Cirrhosis - Bleeding Episodes

Vasoconstrictors. Vasoconstrictors narrow the blood vessels and reduce flow in the spleen. They are particularly effective when used with nitroglycerin.

Vasopressin (Pitressin) is the most commonly used vasoconstrictor. It poses a risk to the heart, however, and it is not clear whether it is actually helpful.
Terlipressin is a synthetic version of vasopressin that is proving to be as effective as sclerotherapy in controlling bleeding. It also lacks vasopressin's side effects and may prove to prolong survival and serve as bridge for patients waiting for liver transplantation.

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Endoscopic Procedures Used to Stop Bleeding and Prevent Recurrence

Endoscopic procedures employ a tube inserted down through the esophagus that contains microcameras and tiny instruments. Endoscopy is used both to diagnose the disease and stop bleeding. The two standard procedures are band ligation and sclerotherapy. In general, a combination of drug therapies and an endoscopic procedure is the usual approach for preventing a bleeding recurrence.

Endoscopic Band Ligation. In endoscopic band ligation, latex bands are wrapped around the bleeding varices, shutting off the blood supply. It is the method of choice to control of bleeding and, in weekly sessions, to prevent rebleeding, because it has a lower risk for complications than sclerotherapy. Recurrence rates are higher with band ligation, however. Studies are mixed on whether weekly treatments with band ligation any more effective in preventing rebleeding than beta-blockers plus isosorbide mononitrate. A combination of medications plus band ligation is under investigation.

Investigators are studying argon plasma coagulation (APC) after band ligation to prevent variceal recurrence and rebleeding. This procedure employs argon gas to deliver electric currents that coagulate and stop bleeding. In one small study, no recurrence of varices or bleeding occurred after APC, while recurrence occurred in 42% and bleeding in 7.2% of patients without the argon procedure. More work is warranted.

Endoscopic Sclerotherapy. Endoscopic sclerotherapy is only effective against bleeding in the esophagus. The endoscopic tube is inserted through the mouth. Agents are injected through what are called sclerosants (polidocanol and others). They toughen the tissue around the variceal blood vessels. The procedure is repeated over a period of two or three months. Repeat treatments appear to reduce rebleeding and death. Minor complications (usually ulcers in the mucus membranes) are common and serious complications can occur (narrowing or perforation of the esophagus and leakage at the injection site.)