Management of Acute Variceal Bleeding: Review of APASL Guidelines by Dr. Cosmas Rinaldi A. Lesmana

Management of Acute Variceal Bleeding: Review of APASL Guidelines

Summary of Lecture by Dr. Cosmas Rinaldi A. Lesmana

1. Main Clinical Topics Discussed

• Acute variceal bleeding (AVB) in the context of liver cirrhosis and portal hypertension
• Updated APASL (Asian Pacific Association for the Study of the Liver) 2025 guidelines on AVB management
• Coagulopathy management in advanced liver disease
• Pharmacological, endoscopic, and rescue interventions for AVB

2. Key Learning Points, Guidelines, and Recommendations

Initial Resuscitation & Airway Management

• ABC protection (Airway, Breathing, Circulation) is the cornerstone of initial management
• Elective intubation is recommended in:

- Massive hematemesis

- Altered mental status

- Suspected gastric variceal bleeding

- Difficulty maintaining oxygen saturation

- Massive ascites

• Fluid replacement should be cautious, targeting stable systolic blood pressure, heart rate, CVP, and diuresis

Coagulopathy Management

• Patients with advanced liver cirrhosis exhibit hemostatic imbalance — unpredictable bleeding vs. thrombotic tendency due to dysregulation of pro- and anti-coagulant factors
• Fresh Frozen Plasma (FFP) and platelet transfusions should be used cautiously due to risk of:

- Fluid overload

- Allergic reactions

- Transfusion-related acute lung injury (TRALI)

- Increased rebleeding rates (per APASL 2025)

• Tranexamic acid may reduce the risk of rebleed post-endoscopic band ligation
• Proton pump inhibitors (PPIs) are helpful in acute upper GI bleeding from non-variceal etiology
• Prothrombin Complex Concentrate (PCC): Limited data; a small 2016 case series by Dr. Lesmana's group showed >80% INR reduction with no bleeding complications or thrombotic events in liver disease patients undergoing invasive procedures

Pharmacological Treatment

• Vasoactive therapy should be initiated within 30 minutes of the index bleed *(High recommendation, strong evidence — APASL 2025)*
• Agents include:

- Terlipressin *(most preferred)*

- Somatostatin

- Octreotide

• Choice depends on availability and patient comorbidities; consistent with AASLD and EASL guidelines

Endoscopic Management

• Endoscopic Band Ligation (EBL) remains the preferred method for esophageal variceal bleeding
• Cyanoacrylate injection via standard endoscopy is preferred for gastric varices
• Timing of endoscopy (APASL 2025):

- Endotherapy should be performed as soon as possible, ideally within 6 hours of admission

- May proceed once patient is stable, within 12 hours, and no later than 24 hours

• Combination of vasoactive drugs + endoscopic therapy remains first-line treatment (consistent across APASL 2011 and 2025)

Rescue/Salvage Therapies

• Balloon tamponade: High success rate in controlling bleeding; still considered where facilities are limited
• Self-expanding metallic stents (SEMS): Effective for refractory variceal bleeding or complications of prior treatment; an emerging alternative to balloon tamponade

3. Specific Clinical Data and Study Results Cited

• APASL 2025 Guidelines published in *Hepatology International* — updated consensus on resuscitation, initial management, and monitoring in AVB
• Lesmana et al., 2016 *(case series)*: PCC use in liver coagulopathy patients undergoing invasive procedures — >80% achieved INR reduction; no bleeding complications or thrombotic events
• Lesmana et al., 2019 *(Gastroenterology Hepatology Open)*: Risk factors for variceal bleeding at one year — multivariate analysis