What is the optimal inpatient management of upper gastrointestinal (GI) bleed in a patient with cirrhosis (liver disease)?

From the Guidelines

The management of upper gastrointestinal bleeding (UGIB) in cirrhotic patients should prioritize a systematic approach that addresses both the acute bleeding and the underlying liver disease, with a focus on hemodynamic stabilization, conservative blood transfusion, vasoactive therapy, antibiotic prophylaxis, and urgent endoscopy. This approach is supported by the most recent and highest quality study, which recommends a restrictive transfusion strategy with a hemoglobin target of 7-8 g/dL 1.

Initial Assessment and Stabilization

The initial assessment should focus on hemodynamic stabilization with two large-bore IV lines for fluid resuscitation using crystalloids, targeting a mean arterial pressure of 65-70 mmHg. Blood transfusion should be conservative, aiming for a hemoglobin target of 7-8 g/dL, as over-transfusion can increase portal pressure and worsen bleeding.

Vasoactive Therapy and Antibiotic Prophylaxis

Administer vasoactive therapy with terlipressin 2mg IV every 4 hours or octreotide 50mcg IV bolus followed by 50mcg/hour infusion to reduce splanchnic blood flow, as recommended by the 2018 EASL clinical practice guidelines 1. Start antibiotic prophylaxis immediately with ceftriaxone 1g IV daily for 5-7 days to prevent bacterial infections, which are common and increase mortality, as supported by the 2018 EASL guidelines 1.

Endoscopy and Therapeutic Intervention

Urgent endoscopy should be performed within 12-24 hours after stabilization to identify the bleeding source and provide therapeutic intervention. For variceal bleeding, band ligation is preferred for esophageal varices, while cyanoacrylate injection is used for gastric varices, as recommended by the 2018 EASL guidelines 1.

Secondary Prophylaxis and Refractory Bleeding

Non-selective beta-blockers (propranolol 20-40mg twice daily or carvedilol 6.25-12.5mg daily) should be initiated after bleeding control for secondary prophylaxis. In cases of refractory bleeding, consider transjugular intrahepatic portosystemic shunt (TIPS) placement, as recommended by the 2007 guidelines 1.

Coagulopathy Management and Monitoring

Coagulopathy management may require fresh frozen plasma, platelets (if <50,000/μL), or vitamin K supplementation. Monitor for hepatic encephalopathy and initiate lactulose 25mL every 1-2 hours until bowel movement, then 15-30mL 2-3 times daily. Assess for acute kidney injury and avoid nephrotoxic medications, as recommended by the 2018 EASL guidelines 1.

Liver Transplantation Evaluation

After stabilization, evaluate the patient for liver transplantation if appropriate, as UGIB indicates decompensated cirrhosis with poor long-term prognosis without definitive intervention, as supported by the 2018 EASL guidelines 1.

Key points to consider:

• Hemodynamic stabilization with fluid resuscitation and conservative blood transfusion
• Vasoactive therapy with terlipressin or octreotide
• Antibiotic prophylaxis with ceftriaxone
• Urgent endoscopy with band ligation or cyanoacrylate injection for variceal bleeding
• Secondary prophylaxis with non-selective beta-blockers
• Consideration of TIPS placement for refractory bleeding
• Coagulopathy management and monitoring for hepatic encephalopathy and acute kidney injury
• Evaluation for liver transplantation after stabilization.

From the Research

Inpatient Management of Upper GI Bleed in Cirrhotic Patients

Overview of GI Bleeding in Cirrhotic Patients

• GI bleeding is a significant clinical event in patients with chronic liver failure or decompensated cirrhosis, with a high short-term mortality rate of 15-25% 2
• The most common source of bleeding is from gastroesophageal varices, but non-variceal bleeding from peptic ulcer disease also carries a significant risk in patients with liver disease 3

Initial Management

• Early initiation of a vasoactive agent and antibiotics is crucial in managing GI bleeding in cirrhotic patients 2
• Conservative transfusion strategies and adequate airway protection are also essential to assist in bleeding control 2
• Blood volume replacement should be initiated as soon as possible, and antibiotic prophylaxis should be instituted from admission 4

Endoscopic Management

• Endoscopic procedures are a critical component of hemostatic treatment for variceal bleeding 4
• Gastroduodenal ulcers are the most frequent source of non-variceal upper GI bleeding in cirrhotic patients, and endoscopic treatment is often required 5
• "High-risk" bleeding stigmata at the ulcer base are common in cirrhotic patients with non-variceal upper GI bleeding, and endoscopic treatment can reduce the risk of rebleeding 5

Transfusion Strategies

• Emerging data suggest that transfusion of packed red blood cells to a hemoglobin threshold of 7-8 g/dL is a suitable strategy for patients with cirrhosis 6
• Viscoelastic testing (VET)-guided transfusions may reduce blood transfusion requirements prior to minor procedures and during orthotopic liver transplantation 6
• The role of hemostatic agents such as recombinant factor VIIa, prothrombin complex concentrates, and tranexamic acid in cirrhotic patients is unclear and requires further study 6

Predictors of Mortality

• Cryptogenic etiology of cirrhosis, hypoalbuminemia, and active bleeding at ulcer base are independent predictors of in-hospital mortality in cirrhotic patients with non-variceal upper GI bleeding 5
• Renal dysfunction and severe hepatic failure are also associated with increased mortality in cirrhotic patients with GI bleeding 5

Portal Decompression and Liver Transplantation

• Portal decompression using transjugular intrahepatic portosystemic shunt placement may be necessary for selected patients with failure to control bleeding or ascites 2
• Early consideration for liver transplantation referral is critical to improve patient survival in cirrhotic patients with GI bleeding 2