From the Guidelines
The treatment of epistaxis in patients with liver cirrhosis should prioritize direct pressure, topical vasoconstrictors, and addressing underlying coagulopathy, with a focus on minimizing bleeding risk and improving quality of life.
Initial Management
- Initial management should focus on direct pressure by pinching the anterior part of the nose for 10-15 minutes while the patient sits upright and leans slightly forward 1.
- If bleeding persists, topical vasoconstrictors like oxymetazoline or phenylephrine nasal spray can be applied.
Coagulopathy Management
- Addressing the underlying coagulopathy is crucial, which may include administering vitamin K, fresh frozen plasma, or platelet transfusions if platelet count is below 50,000/μL, although the latest evidence suggests that correcting coagulopathy may not be as effective in preventing bleeding as previously thought 1.
- In cirrhotic patients, avoid NSAIDs as they can worsen bleeding risk.
Recurrent Epistaxis Management
- For recurrent epistaxis, consider tranexamic acid (1g IV or PO TID) to stabilize clots.
- Endoscopic cauterization by an ENT specialist may be necessary for persistent bleeding.
Long-term Management
- Long-term management should include humidification of the nasal passages with saline sprays and petroleum jelly to prevent recurrence.
- Portal hypertension management with non-selective beta-blockers like propranolol (starting at 20mg BID) may help reduce bleeding risk by decreasing portal pressure in these patients 1.
Key Considerations
- The latest guidelines suggest that the administration of vitamin K to correct prolongations in INR is not supported by evidence, and prophylactic FFP administration should be abandoned due to potential harm 1.
- Platelet transfusions to prevent spontaneous bleeding are only recommended when platelet count is <10 × 10^9/L, and there is no clear-cut evidence suggesting that correction of platelet count prevents spontaneous bleeding 1.
From the Research
Treatment for Epistaxis in Patients with Liver Cirrhosis
- The treatment for epistaxis (nosebleed) in patients with liver cirrhosis is crucial due to their abnormal coagulation status 2, 3.
- Tranexamic acid, an antifibrinolytic agent, has been shown to reduce the risk of re-bleeding in patients with epistaxis, and may be beneficial in patients with liver cirrhosis 4.
- However, there is limited research specifically on the treatment of epistaxis in patients with liver cirrhosis, and more studies are needed to determine the most effective treatment approach 2.
- In patients with cirrhosis, epistaxis can be a complication that triggers hepatic encephalopathy or simulates gastrointestinal bleeding 2.
- Perioperative management of bleeding in patients with cirrhosis should focus on the three pillars of patient blood management: optimization of erythropoiesis, minimization of bleeding and blood loss, and management of anemia 3.
- Intranasal desmopressin has been shown to be effective in correcting coagulopathy in cirrhotic patients undergoing dental extraction, and may be a useful alternative to blood transfusion in some cases 5.
Management Strategies
- Compressive therapy, oxymetazoline nasal spray, and directive nasal cautery are common methods used to control epistaxis in the outpatient setting 6.
- Topical therapy and nasal packing may be used if other methods are unsuccessful 6.
- In patients with liver cirrhosis, careful consideration should be given to the bleeding risk, and coagulation management strategies should be established in advance of procedural interventions 3.
- Viscoelastic testing and restrictive transfusion policies may be useful in managing perioperative bleeding in patients with cirrhosis 3.