What is the management of a GI bleed in a patient with cirrhosis and varices?

Management of GI Bleeding in Cirrhosis with Varices

Acute GI bleeding in a patient with cirrhosis and varices requires immediate intervention with a combination of pharmacological, endoscopic, and supportive therapies to reduce mortality and prevent rebleeding.

Initial Management (First 12 Hours)

Resuscitation and Stabilization

• Volume replacement to restore hemodynamic stability using colloids and/or crystalloids (avoid starches) 1
• Restrictive blood transfusion strategy with hemoglobin threshold of 7 g/dl and target range of 7-9 g/dl 1
• Avoid excessive fluid resuscitation which may increase portal pressure and worsen bleeding

Pharmacological Therapy

• Start vasoactive drugs immediately upon suspicion of variceal bleeding, even before endoscopy 1
  • Options include terlipressin, somatostatin, or octreotide 1
  • Continue for 3-5 days after diagnosis confirmation 1

Antibiotic Prophylaxis

• Initiate short-term (maximum 7 days) antibiotic prophylaxis in all cirrhotic patients with GI bleeding 1
  • First choice in advanced cirrhosis: IV ceftriaxone 1 g/day 1
  • Alternative: Oral norfloxacin 400 mg twice daily 1
  • Consider local resistance patterns when selecting antibiotics 1

Pre-Endoscopy Management

• Consider IV erythromycin (250 mg) 30-120 minutes before endoscopy to improve visualization (if no QT prolongation) 1
• Avoid nephrotoxic drugs, large volume paracentesis, beta-blockers, vasodilators, and other hypotensive medications 1

Endoscopic Management

Timing and Approach

• Perform endoscopy within 12 hours after admission once hemodynamically stable 1
• Identify the source of bleeding and provide appropriate endoscopic therapy

Esophageal Variceal Bleeding

• Endoscopic variceal ligation (EVL) is the preferred method 1
• Combine with vasoactive drugs for optimal results 1
• Schedule follow-up EVL sessions at 7-14 day intervals until varices are obliterated 1

Gastric Variceal Bleeding

• Treatment depends on type of gastric varices:
  • For GOV1 (extension of esophageal varices along lesser curvature): treat like esophageal varices 1
  • For fundal varices (GOV2, IGV1): endoscopic variceal obturation with tissue adhesives like N-butyl-cyanoacrylate is preferred 1
  • Cyanoacrylate shows better control of initial hemorrhage and lower rebleeding rates compared to EVL for gastric varices 1

Rescue Therapies for Uncontrolled Bleeding

Balloon Tamponade

• Use as a temporizing measure (maximum 24 hours) in patients with uncontrollable bleeding 1
• Effective for immediate control but almost universal rebleeding if used alone 1

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

• Indicated when bleeding cannot be controlled or recurs despite combined pharmacological and endoscopic therapy 1
• Consider early pre-emptive TIPS (within 24-72 hours) in high-risk patients 1
• Effective for both esophageal and gastric variceal bleeding 1

Prevention of Complications

Hepatic Encephalopathy Management

• Use lactulose or lactitol when encephalopathy develops 1
• Consider oral non-absorbable disaccharides for prevention 1

Renal Protection

• Preserve renal function with adequate fluid and electrolyte replacement 1
• Avoid nephrotoxic drugs 1

Post-EVL Care

• Consider short-course proton pump inhibitor therapy after EVL to reduce post-banding ulcer size 1

Common Pitfalls and Caveats

1. Delayed endoscopy: Failure to perform endoscopy within 12 hours increases mortality
2. Inadequate antibiotic prophylaxis: Bacterial infections occur in >50% of cirrhotic patients with GI bleeding and worsen outcomes
3. Overaggressive transfusion: Excessive blood transfusion can increase portal pressure and precipitate rebleeding
4. Failure to recognize gastric varices: Different types of gastric varices require different management approaches
5. Delayed consideration of rescue therapies: TIPS should be considered early in high-risk patients or those failing initial therapy

Risk Factors for Rebleeding

• High bilirubin levels 2
• Large varices (grade III/IV) 2
• Advanced liver disease (Child-Pugh C)
• Active bleeding at endoscopy
• Hepatic venous pressure gradient >20 mmHg

By following this algorithmic approach to managing GI bleeding in cirrhotic patients with varices, mortality and rebleeding rates can be significantly reduced.