What is the management approach for resuscitation and monitoring of acute variceal bleeding in cirrhotic patients?

Management of Acute Variceal Bleeding in Cirrhotic Patients

Patients with acute variceal bleeding should be admitted to an intensive care unit for resuscitation and management, with immediate initiation of vasoactive drugs, restrictive blood transfusion targeting hemoglobin of 7-8 g/dL, and prophylactic antibiotics. 1, 2

Initial Resuscitation and Stabilization

Hemodynamic Stabilization

• Establish at least two 16-gauge peripheral IV cannulae 1
• Cross-match 6 units of blood 1
• Maintain hemoglobin around 7-8 g/dL using a restrictive transfusion strategy 1, 2, 3
  • Higher transfusion targets can increase portal pressure, leading to more rebleeding and higher mortality 1
• Establish central venous access for monitoring 1, 2
• Avoid vigorous fluid resuscitation with saline as it may precipitate recurrent bleeding and worsen ascites 1

Airway Protection

• Consider elective intubation in the following scenarios 1, 2:
  • Severe uncontrolled variceal bleeding
  • Severe hepatic encephalopathy
  • Inability to maintain oxygen saturation >90%
  • Aspiration pneumonia

Coagulopathy Management

• Correct significant coagulopathy with fresh frozen plasma and thrombocytopenia with platelet transfusions 1
• Note: Recombinant Factor VIIa is not recommended as standard therapy based on clinical trials 1

Pharmacological Management

Vasoactive Drugs

• Start vasoactive drugs immediately when variceal bleeding is suspected, even before endoscopy 2, 3, 4
• Options include:
  • Terlipressin: 2 mg IV every 4 hours for 48 hours, then 1 mg IV every 4 hours (preferred where available as it's the only agent shown to improve survival) 2, 3
  • Octreotide: Alternative when terlipressin unavailable 1, 2
  • Somatostatin: Alternative when terlipressin unavailable 2, 3
• Continue vasoactive drugs for 3-5 days after bleeding control 2, 3

Antibiotic Prophylaxis

• Administer short-term antibiotic prophylaxis (maximum 7 days) 1, 2
  • Options include:
    • Oral norfloxacin
    • IV ciprofloxacin
    • IV ceftriaxone (preferred in advanced cirrhosis or centers with high quinolone resistance) 2
• This reduces bacterial infections, rebleeding risk, and mortality 1

Endoscopic Management

Timing of Endoscopy

• Perform endoscopy as soon as the patient is hemodynamically stable, ideally within 12 hours of admission 1, 2

Endoscopic Therapy

• For esophageal varices:
  • Variceal band ligation is the first-line treatment (Grade AI recommendation) 1, 2
  • If banding is difficult due to continued bleeding or unavailable, use endoscopic variceal sclerotherapy 1, 2
• For gastric varices:
  • Endoscopic variceal obturation with tissue adhesives like N-butyl-cyanoacrylate 2, 5

Management of Treatment Failure

Definition of Treatment Failure

• Failure to control bleeding or early rebleeding within 5 days (occurs in 10-20% of patients) 3

Rescue Therapies

1. Balloon Tamponade (Sengstaken tube)

   • Use as a temporary bridge (maximum 24 hours) when bleeding is difficult to control 1, 2
   • Requires adequate airway protection 1

2. Transjugular Intrahepatic Portosystemic Shunt (TIPS)

   • First-line rescue therapy for treatment failure 2, 6
   • Consider early TIPS (within 24-72 hours) in high-risk patients:
     • Child-Pugh B with active bleeding
     • Child-Pugh C (<14 points) 2, 3
   • Covered stents are preferred over bare stents 3, 6

3. Surgical Options

   • Consider when TIPS is unavailable or contraindicated 1
   • Options include surgical shunts or esophageal transection 1, 6

Prevention of Rebleeding

• Combination of non-selective beta-blockers and endoscopic band ligation 2
• Schedule follow-up endoscopy for variceal eradication 2
• Evaluate Child-Pugh C patients for liver transplantation 2

Monitoring During Hospitalization

• Monitor for signs of rebleeding (new hematemesis or melena after 24 hours of stable vital signs) 2
• Watch for development of hepatic encephalopathy and renal dysfunction 2
• Maintain hemodynamic stability throughout hospitalization 5

Common Pitfalls and Caveats

1. Overtransfusion: Maintaining hemoglobin >8 g/dL can increase portal pressure and rebleeding risk 1, 3
2. Delayed endoscopy: Failure to perform endoscopy within 12 hours in stable patients increases mortality 2
3. Inadequate duration of vasoactive drugs: Stopping vasoactive drugs too early (<3-5 days) increases rebleeding risk 2, 3
4. Failure to recognize high-risk patients: Not identifying candidates for early TIPS (Child B with active bleeding or Child C <14 points) misses opportunity to reduce mortality 2, 3
5. Neglecting antibiotic prophylaxis: Omitting antibiotics significantly increases infection risk, rebleeding, and mortality 1, 2