UK guidelines on the management of variceal haemorrhage in cirrhotic patients
- Department of Internal Medicine, Royal Infirmary of Edinburgh, Lauriston Place, Edinburgh EH3 9YW, UK
- Dr R Jalan. Email:
These guidelines on the management of variceal haemorrhage were commissioned by the British Society of Gastroenterology under the auspices of the Liver Section. They were written in June 1998 and have been corrected and agreed upon by the members of the Liver Section. The nature of variceal haemorrhage in cirrhotic patients with its complex range of complications makes rigid guidelines inappropriate.
Over the past few years there have been numerous advances in the management of variceal haemorrhage in patients with cirrhosis. These have included better endoscopic techniques with the widespread availability of video endoscopy, establishment of variceal band ligation, availability of newer drugs such as somatostatin and vasopressin analogues, better surgical techniques, and finally the availability of transjugular intrahepatic portosystemic stent shunt (TIPSS).
These guidelines deal specifically with the management of varices in patients with cirrhosis and are not designed to address: (1) the management of the underlying liver disease; (2) the management of variceal haemorrhage in children; or (3) variceal haemorrhage from other aetiological conditions.
2.0 Validity and grading of recommendations
These guidelines have been produced to conform to the system proposed by the North of England evidence based guidelines development project.1 2
2.1 CATEGORIES OF EVIDENCE
These are graded as follows:
- Ia: evidence obtained from meta-analysis of randomised trials.
- Ib: evidence obtained from at least one randomised trial.
- IIa: evidence obtained from at least one well designed controlled study without randomisation.
- IIb: evidence obtained from at least one other type of well designed quasi experimental study.
- III: evidence obtained from well designed non-experimental descriptive studies such as comparative studies, correlation studies, and case studies.
- IV: evidence obtained from expert committee reports, or opinions or clinical experiences of respected authorities.
The evidence category is indicated after the citations in the reference section.
2.2 GRADING OF RECOMMENDATIONS
The strength of each recommendation is dependent upon the category of the evidence supporting it, and is graded according to the system shown in table 1.
It is important to define the terms that should be used in the context of a variceal bleed. These are the consensus definitions.3
3.1 VARICEAL HAEMORRHAGE
Variceal haemorrhage is defined as bleeding from an oesophageal or gastric varix at the time of endoscopy or the presence of large oesophageal varices with blood in the stomach and no other recognisable cause of bleeding. An episode of bleeding …