What are the next steps for a 62-year-old patient in the Intensive Care Unit (ICU) with Acute-on-Chronic Liver Failure (ACLF), who remains intubated and ventilated, and has experienced fresh rectal bleeding and hematemesis after recent endoscopic variceal banding?

From the Guidelines

For a 62-year-old ICU patient with acute-on-chronic liver failure (ACLF) who has experienced rectal bleeding and hematemesis despite recent endoscopic banding, I strongly recommend continuing terlipressin and adding octreotide as adjunctive therapy to control variceal bleeding, as supported by the most recent guidelines 1. The patient should be closely monitored with repeat endoscopy in the next 24-48 hours to assess the banded varices and identify any new bleeding sources.

• Continue terlipressin at 1-2 mg IV every 4-6 hours for vasoconstriction of splanchnic vessels to reduce portal pressure.
• Add octreotide 50 mcg IV bolus followed by 50 mcg/hour continuous infusion as adjunctive therapy, as recommended by recent studies 1.
• Maintain prophylactic antibiotics, specifically ceftriaxone 1g IV daily, to prevent spontaneous bacterial peritonitis and other infections, as suggested by previous guidelines 1.
• Continue hemodynamic monitoring with serial hemoglobin checks every 6 hours, and transfuse packed red blood cells if hemoglobin drops below 7 g/dL, as recommended by older studies 1.
• Optimize coagulation parameters with vitamin K 10 mg IV daily and consider fresh frozen plasma if INR >1.5 with active bleeding.
• Maintain the patient on continuous renal replacement therapy as it helps manage fluid balance and remove toxins in the setting of liver failure. These interventions are crucial because variceal bleeding in ACLF carries high mortality, and early rebleeding is common within the first week after initial control, as highlighted by recent guidelines 1. The combination of pharmacological therapy with endoscopic treatment provides better outcomes than either approach alone by addressing both the immediate bleeding and the underlying portal hypertension, as supported by the most recent and highest quality study 1.

From the Research

Patient Status and Treatment

• The patient is a 62-year-old on ICU with Acute-on-Chronic Liver Failure (ACLF) and remains intubated and ventilated.
• The patient is off cardiovascular support but on terlipressin and antibiotics, and remains on a filter.
• The patient has had fresh rectal bleeding and fresh blood with clots aspirated from the nasogastric tube (NGT), but the hemoglobin (Hb) level is stable and did not require a transfusion.
• The patient was scoped on the 11th and was banded.

Next Steps

• Considering the patient's stable Hb level and lack of requirement for transfusion, the focus should be on managing the gastrointestinal bleeding and preventing re-bleeding 2.
• The use of proton pump inhibitors (PPIs) may be beneficial in reducing the risk of re-bleeding, and studies have shown that intravenous push (IVP) dosing can be as effective as continuous infusion (CI) in hemodynamically stable patients 2.
• However, the patient's underlying liver disease and ACLF should be taken into consideration when managing their care, as PPI exposure has been associated with increased risk of infection and decompensation in cirrhosis 3.

Considerations for PPI Use

• The study by 2 suggests that IVP PPI dosing can be used preferentially in hemodynamically stable patients with suspected upper gastrointestinal bleeding, which may be applicable to this patient.
• However, the study by 3 highlights the potential risks associated with PPI exposure in patients with cirrhosis, and the decision to use PPIs should be made on a case-by-case basis.
• The patient's response to PPI therapy should be closely monitored, and adjustments made as necessary to minimize the risk of adverse outcomes.