In this section
Note: This guideline is currently under review.
Definition of Terms
Oesophageal variceal bleeds (and indeed any variceal bleeds) are a rare but serious complication of portal hypertension. Portal hypertension is defined by an increase in pressure within the portal circulatory system. This increase is caused by vascular resistance in blood
flow through the liver. In RCH’s patient population, portal hypertension is frequently a result of biliary atresia, but it can also be a manifestation of post-hepatic, pre-hepatic (eg portal vein obstruction), or other intra-hepatic problems such as cystic fibrosis, congenital hepatic fibrosis or other
cirrhosis. With increased resistance in the portal vascular system, blood begins to shunt through collateral systemic vessels to return to the vena cava. Prolonged elevation in portal vein pressure causes dilatation of the collateral vessels, which can form internal haemorrhoids at the rectum, caput medusae at
the umbilicus and varices in the fragile gastro-oesophageal veins. Ruptures occur when the variceal wall tension exceeds the wall strength. Children with liver disease also have liver dysfunction, which results in clotting cascade problems and a deficit in Vitamin K-dependent factors. This adds to the risk of
significant haemorrhage in this patient group.
In several large studies of children with portal hypertension, approximately 2/3 presented with haematemesis or melaena, usually from rupture of an oesophageal varix. Twenty to thirty percent of children with biliary atresia have variceal bleeds and they tend to develop
varices early, with an estimated risk of bleeding of 15% before the age of two. Mortality rates associated with large bleeds range from 0-15%.
The aim of this guideline is to assist nurses and other health professionals in the acute management of infants and children experiencing an oesophageal variceal bleed. The guideline will also outline ongoing assessment and adjunctive therapies for the ongoing care of this patient group.
(Refer to algorithm overleaf)
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The development of this nursing guideline was coordinated by Katherine Butler, RN, Emergency Department, and approved by the Nursing Clinical Effectiveness Committee. Updated October 2018.