What is the initial treatment for a patient with cirrhosis experiencing an upper gastrointestinal (GI) bleed?

Management of Upper GI Bleeding in Cirrhosis

The initial treatment for a patient with cirrhosis experiencing an upper gastrointestinal bleed should include immediate administration of vasoactive drugs (terlipressin, somatostatin, or octreotide), antibiotic prophylaxis, restrictive blood transfusion strategy, and early endoscopy with band ligation for variceal bleeding. 1

Initial Resuscitation and Management

Airway and Circulation

• Assess airway patency and consider endotracheal intubation for:
  • Severe uncontrolled bleeding
  • Severe hepatic encephalopathy
  • Inability to maintain oxygen saturation above 90%
  • Risk of aspiration 1
• Establish venous access with at least two 16-gauge peripheral cannulae 1
• Blood volume resuscitation:
  • Use crystalloids (or colloids) for initial volume replacement
  • Follow a restrictive transfusion strategy with hemoglobin threshold of 7 g/dL and target of 7-9 g/dL 1
  • Avoid vigorous saline resuscitation as it can precipitate recurrent bleeding and worsen ascites 1

Immediate Pharmacological Therapy

• Start vasoactive drugs immediately when variceal bleeding is suspected:
  • Terlipressin: 2 mg/4 hours for first 48 hours, then 1 mg/4 hours
  • Somatostatin: 250 μg/h continuous infusion with initial 250 μg bolus (can increase to 500 μg/h)
  • Octreotide: 50 μg/h continuous infusion with initial 50 μg bolus 1
• Continue vasoactive drugs for 3-5 days after successful endoscopic therapy 1

Antibiotic Prophylaxis

• Start antibiotic prophylaxis immediately:
  • Ceftriaxone 1 g/day IV (preferred in advanced cirrhosis - Child B/C)
  • Alternative: Norfloxacin 400 mg BID orally for 7 days 1
• Antibiotics reduce bacterial infections, early rebleeding, and improve survival 1

Endoscopic Management

Timing and Approach

• Perform upper endoscopy as soon as possible within 12 hours after admission and hemodynamic stabilization 1
• Consider administering erythromycin (250 mg IV, 30-120 min before endoscopy) to improve visibility 1

Endoscopic Therapy Based on Bleeding Source

• For esophageal varices:
  • Endoscopic band ligation (EBL) is first-line treatment 1
  • Use sclerotherapy only when banding is technically difficult or not available 1
• For gastric varices:
  • Cyanoacrylate injection is preferred for cardiofundal (gastric) varices
  • EBL can be used for small gastric varices that can be completely suctioned into the ligation device 1

Management of Refractory Bleeding

Rescue Therapy

• For uncontrolled bleeding despite standard therapy:
  • Insert Sengstaken-Blakemore tube as a temporary bridge to more definitive therapy 1
  • Consider self-expandable esophageal stent as an alternative to balloon tamponade 1

Early TIPS (Transjugular Intrahepatic Portosystemic Shunt)

• Consider early TIPS (within 24-72 hours) for:
  • Child-Pugh C patients (score <14)
  • Child-Pugh B patients with active bleeding at endoscopy 1
• Consider emergency/salvage TIPS for variceal bleeding refractory to endoscopic treatment 1

Special Considerations

Non-Variceal Bleeding

• Up to 30% of cirrhotic patients bleed from non-variceal causes 1
• Consider high-dose proton pump inhibitor before endoscopy 1
• Treat according to the specific cause identified on endoscopy

Monitoring and Follow-up

• Monitor in intensive care setting until bleeding is controlled
• Watch for complications including renal failure, hepatic encephalopathy, and infections
• Plan for secondary prophylaxis after acute bleeding is controlled

Pitfalls to Avoid

• Delaying administration of vasoactive drugs while waiting for endoscopy
• Excessive volume resuscitation, which can increase portal pressure and precipitate rebleeding
• Overtransfusion (target Hb 7-9 g/dL, not higher)
• Failing to provide antibiotic prophylaxis, which significantly reduces mortality
• Delaying endoscopy beyond 12 hours in a hemodynamically stable patient
• Not considering early TIPS in high-risk patients

By following this algorithm, mortality from variceal bleeding in cirrhosis can be significantly reduced from historical rates of 30-50% to current rates of approximately 15-20% 2.