From the Guidelines
Bleeding in liver cirrhosis should be managed with immediate medical attention, including stabilizing blood pressure with IV fluids and blood transfusions as needed, followed by vasoactive drug therapy with octreotide or terlipressin, and endoscopic therapy with band ligation or tissue adhesive injection, as recommended by the EASL clinical practice guidelines 1.
Initial Management
The initial management of liver cirrhosis bleeding involves:
- Stabilizing blood pressure with IV fluids and blood transfusions as needed
- Administering vasoactive drug therapy, such as octreotide (starting at 50 mcg IV bolus followed by 50 mcg/hour infusion for 3-5 days) or terlipressin (2 mg IV every 4 hours), to reduce portal pressure and control bleeding 1
- Providing antibiotic prophylaxis, such as ceftriaxone (1 g/24 h) for up to seven days, to reduce the incidence of infections and improve control of bleeding and survival 1
Endoscopic Therapy
Endoscopic therapy is the definitive treatment for liver cirrhosis bleeding, with:
- Band ligation preferred for esophageal varices
- Tissue adhesive injection preferred for gastric varices
- Endoscopic therapy should be performed as soon as possible within the first 12 h after admission, to ascertain the cause of haemorrhage and to provide endoscopic therapy if indicated 1
Secondary Prophylaxis
After the acute bleeding is controlled, patients should receive:
- Non-selective beta-blockers, such as propranolol (20-40 mg twice daily) or nadolol (20-40 mg daily), to prevent rebleeding
- Secondary prophylaxis may include a combination of beta-blockers and endoscopic band ligation 1
Prevention of Complications
Prevention of complications, such as bacterial infections, hepatic encephalopathy, and deterioration of renal function, is crucial in the management of liver cirrhosis bleeding, and can be achieved by:
- Providing antibiotic prophylaxis
- Preserving renal function by adequate replacement of fluids and electrolytes
- Avoiding nephrotoxic drugs, such as aminoglycosides and non-steroidal anti-inflammatory drugs (NSAIDs) 1
From the Research
Liver Cirrhosis Bleeding
- Liver cirrhosis is a major global health burden due to its high risk of morbidity and mortality, with bleeding being a significant complication 2.
- Terlipressin has been recognized as a beneficial treatment for cirrhotic patients with acute variceal bleeding and hepatorenal syndrome (HRS) 2, 3.
- The use of terlipressin in liver cirrhosis-related complications, such as ascites, post-paracentesis circulatory dysfunction, and bacterial infections, remains insufficiently studied 2.
- Patients with cirrhosis have complex alterations in their hemostatic system, and routine diagnostic tests of hemostasis do not reflect hemostatic competence in this population 4.
- In bleeding patients with cirrhosis, prohemostatic therapy is not the first line of management, even in the presence of markedly abnormal platelet counts and/or prothrombin times 4.
Treatment of Bleeding in Liver Cirrhosis
- Terlipressin is an effective drug for HRS reversal in patients with liver cirrhosis and acute-on-chronic liver failure, with documented mortality benefit in HRS and acute variceal bleeding 3.
- Adverse effects of terlipressin, such as gastrointestinal symptoms, electrolyte disturbance, and cardiovascular and respiratory adverse events, should be closely monitored 2, 3.
- The use of proton pump inhibitors (PPIs) in patients with liver cirrhosis should be cautious, as they are associated with an increased risk of spontaneous bacterial peritonitis and increased mortality rates 5.
- There is a concerning overprescription of PPIs in cirrhotic patients, often deviating from established guidelines, which subjects patients to unnecessary risks 5.