Refractory Variceal Bleeding Management

Management options for refractory bleeding include balloon tamponade or Danis Ella stent (bridging therapies), interventional radiology-guided TIPS (IR-TIPS)/balloon-occluded retrograde transvenous obliteration and surgery.

Essential considerations involve terlipressin/octreotide, ceftriaxone, metoclopramide (erythromycin), maintaining mean arterial pressure at ~65 mmHg, securing the airway for HE or continuous bleeding, monitoring ECG and electrolytes, conducting a CT scan for anatomy, hepatocellular carcinoma (HCC) and portal vein thrombosis; involving insulin resistance and maintaining hemoglobin at 7-8 g/dL.

No FFPS is recommended, and TEG-based correction may offer better outcomes. Risk factors for re-bleeding include MELD >17, HVPG >20 and PPG >21.

Post-endoscopic variceal ligation (EVL) monitoring is crucial.

The use of self-expanding metal stents (SEMS) is preferred if available and affordable, with salvage TIPS considered superior to surgery for cirrhosis.

Conversely, surgery is favored over TIPS for extrahepatic portal vein obstruction