Anesthesia for Portal Hypertension and Variceal Bleeding

🔹 Introduction

Portal hypertension (PHT) is defined as an increase in the portal venous pressure gradient (HVPG > 5 mmHg; clinically significant if >10-12 mmHg). The most common cause is cirrhosis. One of its most feared complications is esophageal variceal bleeding, which is a medical emergency with high mortality.

🔹 Pathophysiology of Portal Hypertension

1. Increased portal inflow due to splanchnic vasodilation (NO-mediated).
2. Increased intrahepatic resistance (fibrosis, regenerative nodules).
3. Formation of collaterals → esophageal, gastric varices, hemorrhoids, caput medusae.
4. Hyperdynamic circulation: ↑CO, ↓SVR, ↓MAP.
5. Associated complications:
• Coagulopathy (↓synthesis of factors, thrombocytopenia)
• Hepatic encephalopathy
• Ascites, hepatorenal syndrome (HRS)
• Hypoalbuminemia → ↓oncotic pressure

🔹 Variceal Bleeding: Clinical Aspects

• Presents as hematemesis, melena, or hematochezia.
• Life-threatening hypovolemia and airway compromise are key anesthetic concerns.
• Emergency EGD with band ligation or sclerotherapy is both diagnostic and therapeutic.

🔹 Pre-Anesthetic Evaluation

1. Airway & Aspiration Risk

• High risk of aspiration due to active bleeding.
• Full stomach status → RSI likely.
• Consider endotracheal intubation before endoscopy if altered mental status, uncontrolled bleeding, or encephalopathy.

2. Hemodynamic Status

• Check for shock, hypovolemia, tachycardia, hypotension.
• Monitor for ongoing blood loss.

3. Liver Function Assessment

• Child-Pugh Score: A, B, or C
• MELD Score: Predicts perioperative mortality
• Associated issues: coagulopathy, encephalopathy, ascites

4. Hematology & Coagulation

• Thrombocytopenia, prolonged PT/INR, ↓fibrinogen
• May require correction (FFP, platelets, cryoprecipitate)

5. Renal Function

• Look for hepatorenal syndrome
• Avoid nephrotoxic drugs (aminoglycosides, NSAIDs)

6. Electrolytes

• Common: hyponatremia, hypokalemia
• Correct preoperatively

7. Infections

• SBP, UTIs, pneumonia
• Empirical antibiotics may be given (e.g. ceftriaxone)

🔹 Anesthetic Considerations for EGD / Variceal Banding / Sclerotherapy

🔸 1. Setting

• ICU, emergency endoscopy suite, or OR with full resuscitation backup.
• Equipment for difficult airway, suction, emergency drugs, and ventilator.

🔸 2. Airway Management

• Elective intubation recommended for:
• Uncontrolled active bleeding
• Hemodynamic instability
• GCS < 8 or altered sensorium (encephalopathy)
• Need for multiple endoscopic procedures
• Rapid Sequence Induction (RSI):
• Propofol (cautious), Etomidate, or Ketamine (if hypotensive)
• Succinylcholine or rocuronium
• Cricoid pressure until airway secured
• Risk of rebleeding if airway trauma occurs

🔸 3. Monitoring

• Minimum: ECG, NIBP, SpO2, EtCO2
• Arterial line: for frequent ABG and BP monitoring (in severe cases)
• Central line: if fluid/blood resuscitation ongoing

🔸 4. IV Access

• At least two large-bore IV cannulas
• Blood group and crossmatch
• Massive transfusion protocol if needed

🔸 5. Resuscitation & Hemodynamics

• Avoid over-transfusion → increases portal pressure → rebleeding
• Goal Hb: 7-8 g/dL
• Use vasopressors (norepinephrine preferred) if hypotensive despite fluids
• Correct coagulopathy:
• FFP for INR >1.5
• Platelets if <50,000
• Cryoprecipitate if fibrinogen <100 mg/dL

🔸 6. Drugs

• Antibiotics: prophylactic ceftriaxone
• Octreotide/Terlipressin: reduce portal pressure
• Lactulose: if encephalopathy

🔹 Anesthesia Technique

🔹 Sedation Protocol (for stable, elective cases)

• Midazolam 0.02–0.05 mg/kg
• Fentanyl 0.5–1 mcg/kg
• Propofol (TIVA or bolus) titrated carefully
• Supplemental oxygen with nasal prongs or mask
• Risk of apnea, hypoxia – monitor closely

Note: Sedation-only cases require a skilled assistant to manage airway and suction blood.

🔹 Complications to Anticipate

1. Aspiration pneumonia
2. Hypoxia during EGD
3. Hemodynamic collapse due to bleeding or vasodilators
4. Airway obstruction or trauma
5. Encephalopathy exacerbation post-procedure
6. Rebleeding due to elevated portal pressure

🔹 Postoperative Management

• Admit to ICU
• Maintain intubation if encephalopathy, respiratory failure
• Continue vasopressors, octreotide, antibiotics
• Monitor for signs of rebleeding
• Serial labs: ABG, CBC, coagulation
• Plan for definitive management (e.g., TIPSS, surgery)

🔹 Role of TIPSS (Transjugular Intrahepatic Portosystemic Shunt)

• Used in refractory variceal bleeding
• Performed under fluoroscopy-guided sedation or GA
• Anesthetic considerations:
• Coagulopathy
• Encephalopathy risk post-TIPSS
• Blood loss
• Jugular venous access

🔹 Viva & MCQ Pearls

• Best airway management in active variceal bleed? → RSI with ETT
• Drug to reduce portal pressure acutely? → Terlipressin/Octreotide
• Definitive treatment for refractory bleeding? → TIPSS
• Blood product for coagulopathy in cirrhosis? → FFP
• Why avoid over-transfusion in variceal bleed? → Raises portal pressure → rebleeding

🔹 Summary