Surgical Science, 2011, 2, 198-203
doi:10.4236/ss.2011.24044 Published Online June 2011 (http://www.SciRP.org/journal/ss)
Prognostic Factors, Incidence and Management for Acute
Variceal Bleeding in the Liver Transplantation Era*
Élio Rodrigues da Silva1, Ilka de Fátima Santana Ferreira Boin2, Eurípedes Soares Filho3,
Patrícia Alexsandra Nunes Barros Rodrgiues3, Benedito Borges da Silva3
1General Surgeon Collaborator of Department of Surgery, Federal University of Piauí
2Department of Surgery–Clinical Coordinator of Unit of Liver Transplant–Faculty of Medical
Sciences at the State University of Campinas–UNICAMP/SP, Brazil
3Federal University of Piau í
Received February 5, 2011; revised April 6, 2011; accepted May 19, 2011.
Abstract
Background: Gastroesophageal varices are the most common and clinically important part of the portosys-
temic collaterals due to their tendency to rupture and cause massive gastrointestinal bleeding. Objective: The
aim of this work was to evaluate retrospectively the incidence and the factors of prediction for the treatment
of bleeding by gastroesophageal varices in the patients attended in the Emergency Room of the Hospital
State University of Campinas (Brazil) from the last ten years. Methods: The method used here consisted of a
descriptive and retrospective study carried out from the analyses of the medical records of 769 patients with
upper gastrointestinal bleeding of which 220 were admitted because of upper gastrointestinal bleeding
caused by gastroesophageal varices during this same period. Results: The results showed that the gastroe-
sophageal varices appeared in 28.6% of the patients and they were the second most common cause of upper
gastrointestinal bleeding. While evaluating factors such as age, sex and the common individual records, it
was proved that this disease occurs mainly among people between the third and the fifth decade of life, with
the great majority of cases occurring in the fourth decade (29.2%), of which 76.8% were male. There was an
association of hematemesis and melena in the admission of 57.7% of the patients and even ascites was a
common diagnosis in 48.2% of them. Most of these patients (40%) were classified as Child class B at admis-
sion. The early endoscopic exam was used for 96.8% of them and showed the presence of F3 varices in
38.5%, CB varices in 25.1% and RCS varices in 12.6%. Most of these varices (41.5%) were situated in the
distal third of the esophagus. The most used pharmacological treatment was based on octreotide in 45.9% of
the patients. They received 0.05 mg of intravenous octreotide and a maintenance dose of 1 mg per day in
98.6% of the cases, with efficacy in 74.2% of the patients. The tamponade with Sengstaken-Blakemore tube
was applied in 30.5% of the patients, but it was observed that 69.7% of them did not present any consider-
able progress and this situation led to their death. The endoscopic treatment was performed in 41.8% of the
patients with efficacy in 81.5% of them. The sclerotherapy was used for 60.9% of the studied cases with
Ethamolin® being the most used for sclerosing. Emergency surgery was used in just 8.6% of the patients
studied and it controlled the bleeding in 78.9% of the cases. Conclusions: We concluded that gastroesophageal
bleeding was an important cause of upper gastrointestinal hemorrhage, even in the liver transplantation era.
Factors of prediction for this bleeding were the endoscopic classification, the presence of ascites and the de-
gree of liver failure, according to the Child-Pugh classification.
Keywords: Liver Transplantation, Portal Vein Thrombosis, Surgical Technique
1. Introduction
*Master Thesis from the Postgraduate Course in Medical Science in
Surgical General at the “Mestrado Interinstitucional UNICAMP/UFPI–
Faculty of Medical Sciences at the State University of Campinas–
UNICAMP/SP, Brazil.
Bleeding from gastroesophageal varices is still an im-

É. R. da SILVA ET AL.
199
portant cause of hospital internment all over the world
and is also one of the most severe consequences of portal
hypertension [1-14]. This specific type of bleeding is an
immediate threat to life. The mortality of each bleeding
episode varies from 20% to 30%, even increasing from
70% to 90% among patients that are seriously sick [1,7,
11,12,20-32]. However, the cause of rupture of these
varices is not totally clear. Many technological advances
have taken place in the diagnosis and treatment of portal
hypertension. However, it still causes serious complica-
tions such as upper gastrointestinal bleeding (caused by
gastroesophageal varices) and spontaneous bacterial
peritonitis (caused by ascites).
The purpose of this work was to analyze retrospec-
tively the incidence, the factors of prediction, and results
after treatment of bleeding caused by gastroesophageal
varices.
2. Patients and Methods
This research included only those patients who came
from the Emergency Room of the Hospital das Clínicas–
State University of Campinas (UNICAMP)–SP/Brazil
with a diagnosis of upper gastrointestinal bleeding caused
by gastroesophageal varices. This retrospective study
used information collected from 769 patient medical re-
cords of the Emergency Room of the Hospital das Clíni-
cas–State University of Campinas–SP/Brazil from the
last ten years.
The data used were: age, gender, type of bleeding, as-
cites or hepatic encephalopathy presence, portal hyper-
tension etiology, Child-Pugh classification, treatment
type and success and evolution during acute phase and
one-year after.
The degree of upper gastrointestinal bleeding was
classified as mild (little bleeding, without hemodynamics
repercussion); moderate (mild clinical manifestation,
such as fainting, sweating, cutaneous paleness and stable
hemodynamics); and severe (intensive hemodynamics
repercussion, such as hemorrhagic shock).
Diagnosis of upper gastrointestinal bleeding and clas-
sification of varices were carried out according to the
procedure and protocol defined by the endoscopic team
at the institution.
Qualitative variables were evaluated with the Chi-square
test and Fisher’s exact test. Continuous variables were
evaluated with the Mann-Whitney and Kruskal-Wallis
tests. Categorical variables were evaluated with the Stu-
art-Maxwell test. Survival analyses employed the Kap-
lan-Meier method with Log-Rank or Breslow tests. Sta-
tistical significance was designated at P < 0.05.
3. Results
Gastroesophageal varices were the second most frequent
cause of upper gastrointestinal bleeding in our service
representing 220 (28.6%) of the analyzed cases. It was
surpassed only by peptic ulcer disease (Table 1). One
hundred and sixty-nine patients (76.8%) were male. The
age of most patients was between the third and the fifth
decade of life, with a peak in the fourth decade (29.2% of
the cases).
One hundred and twenty patients (57.7%) were admit-
ted with a diagnosis of hematemesis associated with
melena, with variceal bleeding at a moderate level in
47.3% of the cases and severe in 14.5%.Thirty-one
(14.6%) of them died after admission. Among the symp-
toms and clinical signs identified in those patients, as-
cites was present in 106 (48.2%) and liver encephalopa-
thy in 40 (18.2%). Most of them were classified as Child
class B at admission (40%). Alcohol was identified as
the main cause of portal hypertension in 32.3% of the
cases, followed by schistosomiasis (19.1%) and viral
hepatitis C in 10% (Table 2).
Upper gastrointestinal endoscopy was carried out in
213 (96.8%) patients in the first 24 hours after admission.
It showed, according to Osaka’s classification (1979), F3
(38.5%), CB (25.1%), RCS (12.6%) and LM (41.5%)
varices.
Most of these patients (45.9%) were submitted to a
treatment with octreotide, with good response in 74.2%
of the cases. Sengstaken-Blakemore tube was used in
30.5% of the patients admitted with a diagnosis of upper
gastrointestinal bleeding due to gastroesophageal varices,
controlling the bleeding in 49.3% of the cases, Endo-
scopic therapy was used in 41.8% of the patients. Elastic
Table 1. Frequency of the causes of upper gastrointestinal
bleeding in the Emergency Room of the Hospital de Clini-
cas–UNICAMP (Brazil).
Causes Of Upper Gastrointestinal Bleeding Frequency (%)
Peptic Ulcer Disease 264 (34.3%)
Esophageal Varices 220 (28.6%)
Acute Gastroduodenal Mucosal Lesions 209 (27.2%)
Gastric Neoplasms 27 (3.5%)
Esophagitis 23 (3.0%)
Mallory-Weiss 13 (1.7%)
Esophageal Neoplasms 10 (1.3%)
Esophageal Ulcers 03 (0.4%)
Total 769

200 É. R. da SILVA ET AL.
Table 2. Frequency of portal hypertension causes identified
in the patients admitted to the bleeding caused by gastroe-
sophageal varices in the Emergency Room of the Clinical
Hospital–UNICAMP (Brazil).
Portal Hypertension Causes Frequency
Alcohol 71 (32.3%)
Schistosomiasis 42 (19.1%)
Viral Hepatitis C 22 (10.0%)
Viral Hepatitis B 07 (3.2%)
Idiopathic 34 (15.5%)
HCC and Cirrhosis 05 (2.3%)
Autoimmune hepatitis 04 (1.8%)
Budd-Chiari Syndrome 03 (1.4%)
Others 32 (14.4%)
Total 220 (100.0%)
HCC = hepatocellular carcinoma
band ligation technique was applied in 39.1%. The etha-
nolamine oleate was the most used sclerotic substance,
and in 57.6% of the cases only one session was enough
to stop the bleeding that had variceal origin.
Only nineteen patients (0.6%) were submitted to a
surgical treatment during the acute episode of bleeding.
In these cases, the procedure of esophagogastric devas-
cularization associated with splenectomy (EGDS) was
carried out in 63.2% of the patients. The control of
bleeding was successful in 78.9% of the cases.
In the admission period 2.3% of the patients died, and
this index went up to 14.6% after hospital internment.
In the one-year follow-up period only two patients
(1.1%) were submitted to a liver transplantation. In this
period, 20.7% of those who were classified as Child class
B at admission changed to Child class A. Survival rate
after one-year was higher for Child class A (Figure 1).
4. Discussion
Gastroesophageal varices are the most common cause of
bleeding and one of the main causes of death among pa-
tients admitted with a diagnosis of portal hypertension.
These varices are also the most severe complication of
portal hypertension that may occur in cirrhotic patients
[1,7,20]. This medical condition, with upper gastrointes-
tinal bleeding caused by gastroesophageal varices, indi-
cates in most cases a substantial hematemesis that can be
followed by melena or hematochezia. It was discovered
that only 14.5% of the analyzed patients were suffering
from serious bleeding. Apart from this, there was a ten-
dency of association between the admission data and the
Figure 1. Comparison of patient survival rate betw een Child
A and Child B and Child C. Patient survival in the Child A
was significantly better than in the Child B or C (p < 0.001)
patients’ evolution. Thus, a higher number of deaths oc-
curred among those patients admitted with a diagnosis of
hematemesis or hematemesis and melena (20 and 29.1%,
respectively) in comparison to those that were admitted
with a diagnosis of only melena (10.8%). This result is
probably a result of the poor medical condition.
Gastroesophageal varices are a consequence of portal
hypertension, which, in most of the severe cases, are
associated with complications such as ascites, liver en-
cephalopathy, flapping, liver failure and even death due
to hemorrhagic shock [12,28,31]. During the admission
period to the Emergence Room of Clinical Hospital-
UNICAMP, a large number of the patients showed as-
cites (48.2%), although other factors to indicate the level
of seriousness of portal hypertension were not found.
The degree of liver encephalopathy is expressed by
neuropsychological alterations that have a metabolic
origin and are potentially reversible, reflecting the func-
tional aggravation of the liver. In this study 30.8% of
admitted patients had degree I, with an equivalent pro-
portion of patients with degree II.
The classification of Child-Turcotte, modified by Pugh,
defines three distinct groups (A, B or C) that represent
the degree of liver failure. This classification shows an
important prognostic value in terms of mortality of these
patients [14,16,22]. Most of them were classified as
Child class B at admission (40%). However, during one
year a significant change was observed in the classifica-
tion of Child-Turcotte-Pugh in consequence of the ap-
plied treatment. After this period, 20.7% of those who
were classified as Child class B at admission stayed in
Child class A, while 39.3% of those classified as Child
class C at admission changed to Child class B. Accord-
ing to the Child-Turcotte-Pugh classification, survival
rate after one-year was higher for Child class A, (85%),

É. R. da SILVA ET AL.
201
followed by Child class B (55%) and Child class C
(47%). These data show the necessity of classification of
patients according to Child-Pugh due to its great prog-
nostic value.
A variceal hemorrhage, in general, occurs without ob-
vious precipitating factors and without pain. In the ad-
mission period 2.3% of the patients died, and this index
went up to 14.6% after hospital internment, similar to the
results mentioned in the literature [11,12,14,21,27,28].
The endoscopic diagnosis is carried out by observing
the right place of the bleeding or viewing varices that
have a considerable size varying from moderate to big in
those cases where there is no other lesion that could jus-
tify the bleeding [1,6]. Early upper gastrointestinal en-
doscopy (in the first 24 hours after the beginning of
bleeding) has been recommended because it allows the
application of the adequate therapeutic treatment [14].
Two hundred and thirteen patients (96.8%) were submit-
ted to upper gastrointestinal endoscopy in the first 24
hours after admission to the hospital. According to
Osaka’s classification (1979), there were F3 varices in
38.0% of the patients, CB varices in 25.1% and RCS
varices in 12.6%. The highest percentage (41.5%) was
situated in the distal esophagus.
Pharmacological treatment in acute bleeding is based
on the use of vasoconstrictors (vasopressin or soma-
tostatin and similar, β-adrenergic blockers) and ni-
trovasodilators [5,10,13,14]. Most of those patients 51
(45.9%) were submitted to a treatment with octreotide, a
substance that is similar to somatostatin, with a dose of
0,05mg IV and maintenance of 1mg a day during an av-
erage period of four days, succeeding in 74.2% of the
cases.
The tamponade of gastroesophageal varices is indi-
cated only in cases of acute bleeding or when the use of
vasoconstrictors, sclerotherapy and embolization does
not obtain any success. The success of the method varies
between 44 to 90% of the cases [14,15,18,23]. The tam-
ponade with a Sengstaken-Blakemore tube was used in
30.5% of the patients admitted with a diagnosis of upper
gastrointestinal bleeding by gastroesophageal varices,
used during a period of 24 hours in 49.2% of the cases.
This treatment had succeeded in controlling bleeding in
49.3% of the cases, confirming the data contained in the
literature referred to [14,15,18,23].
Endoscopic intervention (with sclerosis or ligature of
varices) could be used as an optional treatment against
acute variceal bleeding. A considerable control of the
bleeding was reached in cases submitted to this treatment
varying from 75 to 90% [2]. Many substances with scle-
rotic properties can be used. However, if the bleeding
persists after the initial sclerotherapy, a second session
should be used in a period of 24 hours; if it still persists,
another therapeutic treatment has to be used. During the
treatment process, new sessions might be carried out
with a view to eradicating the varices and, at the same
time, preventing new bleeding [3,8,9,14,15,29-32]. En-
doscopic intervention was used in 41.8% of the patients,
the elastic band ligation technique was applied to 39.1%
of them and sclerotherapy to the others (60.1%). The
ethanolamine oleate was the most used sclerotic sub-
stance, and in 57.6% of the cases only one session was
enough to stop the bleeding that had a variceal origin.
During a one-year period, the number of necessary ses-
sions to eradicate the varices varied from three to nine
sessions in some cases.
Emergency surgery is usually carried out for only 15
to 25% of the patients that keep on bleeding in spite of
treatment with non-surgical therapy [4,13,15]. Some
Brazilian authors have demonstrated that it is possible to
use the distal splenorenal shunt in the emergency period
because of the satisfactory results obtained [19, 24].
Only nineteen patients (8.6%) were submitted to a surgi-
cal treatment during the acute episode of bleeding. In this
situation the process of esophagogastric devasculariza-
tion associated with splenectomy (EGDS) was applied to
63.2% of the patients. There was a successful control of
bleeding in 78.9% of the cases. In the first following year,
5.2% of the other patients were submitted to surgical
treatment after new episodes of upper gastrointestinal
bleeding caused by gastroesophageal varices.
A liver transplant is the only procedure that has a great
potential to control the bleeding, to correct the portal
hypertension and to restore the normal liver function. It
is an option for those patients with an advanced liver
disease with possible variceal bleeding complications
[16,17,24,25]. However, a great percentage of patients
with bleeding caused by varices cannot be submitted to a
transplant due to factors such as advanced age, drug
abuse, non-compliance, active alcoholism or advanced
diseases in other organs and long time in waiting list
because of the shortage of donor organs [4,16,26]. In this
work only two patients (1.1%) were submitted to a liver
transplant during a one-year period. Recent reports
showed that portal blood flow-preserving procedures
performed by a highly skilled surgical team in a well-
selected patient population offer excellent results, with
very low operative mortality rate (1%), very good 5-year
survival, low encephalopathy rate and a low rebleeding
rate. No other option can offer such promising results.
Therefore, these portal blood flow-preserving procedures
have an important role for patients waiting for a liver
transplantation [4,16].
In conclusion, the incidence of upper digestive hem-
orrhage caused by acute variceal bleeding was 28.6% in
our Emergency Room with low mortality rate. It is im-

202 É. R. da SILVA ET AL.
portant to consider that the gastroesophageal varices are
still a significant cause of upper gastrointestinal bleeding
and may lead to death. Significant prognostic factors were
liver failure score, according to Child-Pugh-Turcotte’s
classification and the efficiency of the applied treatments.
We conclude that portal hypertension treatment should
be considered again.
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