What is the management approach for liver bleeding?

From the Guidelines

Management of liver bleeding requires a systematic approach based on the severity and cause of hemorrhage, with initial management focusing on hemodynamic stabilization and correction of coagulopathy, as recommended by the most recent guidelines 1. The approach to managing liver bleeding involves several key steps, including:

• Hemodynamic stabilization with intravenous fluid resuscitation and blood product transfusion to maintain adequate circulation
• Correction of coagulopathy with fresh frozen plasma, platelets, and cryoprecipitate, as necessary
• Use of specific medications, such as tranexamic acid, to inhibit fibrinolysis and promote clot stability
• Endoscopic intervention, including band ligation or sclerotherapy, for variceal bleeding
• Angiographic embolization for persistent bleeding
• Surgical options, such as perihepatic packing, direct vessel ligation, or partial hepatectomy, for trauma cases The management approach varies based on etiology, with trauma requiring damage control surgery and cirrhosis-related bleeding focusing on reducing portal hypertension and preventing recurrence through beta-blockers like propranolol, as supported by recent studies 1. In cases of liver trauma, non-operative management (NOM) may be considered for hemodynamically stable patients, with angiography and angioembolization (AG/AE) used as a first-line intervention in hemodynamically stable patients with arterial blush on CT scan, as recommended by the World Society of Emergency Surgery (WSES) guidelines 1. Overall, the management of liver bleeding requires a multidisciplinary approach, with consideration of the underlying cause and severity of the hemorrhage, as well as the patient's overall clinical condition, to optimize outcomes and minimize morbidity and mortality.

From the Research

Management Approach for Liver Bleeding

The management of liver bleeding, particularly in patients with cirrhosis, involves a comprehensive approach that considers the underlying pathophysiology and the specific clinical scenario.

• The traditional view of cirrhosis as a condition characterized by a bleeding tendency has been challenged, with evidence suggesting that patients with cirrhosis have a rebalanced hemostatic system with hypercoagulable elements 2.
• As a result, routine correction of hemostasis laboratory values, such as platelet count and prothrombin time, is not recommended, even in the presence of markedly abnormal values 2.
• Instead, the management of bleeding in patients with cirrhosis should focus on addressing the underlying cause of the bleeding, such as variceal bleeding or post-procedural bleeding 2.

Variceal Bleeding

Variceal bleeding is a common complication of cirrhosis, and its management involves a combination of pharmacological and endoscopic therapies.

• The use of nonselective beta-blockers has been shown to prevent variceal hemorrhage and ascites in patients with cirrhosis and clinically significant portal hypertension 3.
• In patients with acute variceal bleeding, the placement of a transjugular intrahepatic portosystemic shunt (TIPS) may be necessary to control bleeding and prevent recurrence 3.
• Thromboelastography-guided blood product transfusion has been shown to reduce the amount of blood products transfused in patients with variceal bleeding, without compromising hemostasis 4.

ICU Admission

Patients with liver disease, particularly those with cirrhosis, may require admission to the intensive care unit (ICU) for management of severe complications such as bleeding, hepatic encephalopathy, and infections.

• Hemodynamically significant esophageal/gastric variceal bleeding and grade 4 hepatic encephalopathy are definitive indications for ICU admission 5.
• Patients with severe hepatorenal syndrome or respiratory failure may also benefit from early ICU treatment, as they have increased baseline mortality 5.
• Rapid identification of sepsis in patients with liver cirrhosis is crucial for ICU admission, and prioritizing cases based on mortality risk and clinical urgency enables efficient resource utilization and optimizes patient management 5.