What are the pathophysiology, clinical manifestations, and treatment options for cirrhosis, upper gastrointestinal (GI) bleeding, and spontaneous bacterial peritonitis (SBP)?

From the Guidelines

For a comprehensive presentation on cirrhosis, upper GI bleeds, and spontaneous bacterial peritonitis (SBP), I recommend focusing on pathophysiology, diagnosis, and evidence-based management strategies for each condition, prioritizing the most recent and highest quality study available, which is the 2020 study by the KASL 1.

Pathophysiology and Diagnosis

Cirrhosis represents the end stage of chronic liver disease characterized by fibrosis and nodule formation. Management includes addressing the underlying cause (alcohol cessation, treating viral hepatitis), preventing complications, and monitoring for decompensation. Patients require regular screening for varices, hepatocellular carcinoma, and assessment of liver function.

Variceal Upper GI Bleeds

For variceal upper GI bleeds, immediate management includes:

• Hemodynamic stabilization with IV fluids and blood products to maintain hemoglobin >7-8 g/dL.
• Pharmacotherapy with octreotide 50 mcg IV bolus followed by 50 mcg/hr infusion for 3-5 days and IV antibiotics (ceftriaxone 1g daily) to prevent infection, as recommended by the 2020 KASL guidelines 1.
• Endoscopic therapy with band ligation for esophageal varices or cyanoacrylate for gastric varices should be performed within 12 hours.
• Secondary prophylaxis includes non-selective beta-blockers (propranolol 20-40mg BID or nadolol 20-40mg daily, titrated to heart rate 55-60 bpm) and scheduled endoscopic band ligation.

Non-Variceal Upper GI Bleeds

For non-variceal upper GI bleeds, high-dose proton pump inhibitors (esomeprazole or pantoprazole 80mg IV bolus followed by 8mg/hr infusion for 72 hours) should be initiated, with endoscopy within 24 hours. Endoscopic hemostasis techniques include epinephrine injection, thermal coagulation, and mechanical clips.

Spontaneous Bacterial Peritonitis (SBP)

SBP diagnosis requires paracentesis showing ascitic fluid neutrophil count >250 cells/mm³.

• Empiric treatment includes cefotaxime 2g IV every 8 hours or ceftriaxone 1g IV daily for 5-7 days, as recommended by the 2010 EASL guidelines 1.
• Alternatives include fluoroquinolones like ciprofloxacin 400mg IV twice daily.
• SBP prophylaxis is indicated for patients with prior SBP (norfloxacin 400mg daily or ciprofloxacin 500mg daily), ascitic fluid protein <1.5 g/dL with impaired renal function or liver failure.
• Albumin administration (1.5 g/kg on day 1 g/kg on day 3) improves survival by preventing hepatorenal syndrome, as recommended by the 2020 Anaesthesia study 1.

Comprehensive Care

Throughout management, addressing portal hypertension, maintaining nutrition, avoiding hepatotoxins, and timely referral for liver transplant evaluation when appropriate are essential components of comprehensive care for these patients with advanced liver disease.

From the Research

Cirrhosis Overview

• Cirrhosis is a condition where the liver is severely scarred, often due to chronic liver failure or decompensated cirrhosis 2
• It can lead to various complications, including gastrointestinal (GI) bleeding and ascites

Upper GI Bleeds

• GI bleeding in patients with cirrhosis carries a high short-term mortality (15-25%) 2
• Early initiation of a vasoactive agent and antibiotics, as well as timely endoscopic management, is crucial for bleeding control 2
• Conservative transfusion strategies and adequate airway protection are also important for bleeding control 2
• Antibiotic prophylaxis has been shown to improve outcomes in patients with cirrhosis and upper GI bleeding, with a shorter course of antibiotics (3 days) appearing safe and adequate for prophylaxis 3

Spontaneous Bacterial Peritonitis (SBP)

• SBP is a common complication in patients with liver cirrhosis, with an increased risk of mortality 4, 5, 6
• The incidence of SBP varies between 7% and 30% in hospitalized patients with cirrhosis and ascites 4
• Early antibiotic treatment of SBP is crucial, with the selection of empirical antibiotic treatment guided by the severity and location of the infection, risk factors for multidrug-resistant organisms, and local expected bacteriology 4
• The use of albumin as a complementary therapy for selected high-risk patients with SBP is recommended in addition to antibiotics 4
• Prompt diagnosis of SBP is key to reducing mortality rates, with diagnostic paracentesis recommended in all patients with ascites and clinical features with high diagnostic suspicion 6

Treatment and Management

• Portal decompression using transjugular intrahepatic portosystemic shunt placement may be considered for selected patients with failure to control bleeding or ascites 2
• Early consideration for liver transplantation referral is critical to improve patient survival 2
• Antibiotic prophylaxis has been recommended in high-risk settings to prevent SBP, with careful selection of high-risk candidates crucial to avoid antibiotic overuse 4, 5