What is the management approach for a patient with cirrhosis presenting with a gastrointestinal (GI) bleed?

Management of GI Bleeding in Cirrhosis

The management of gastrointestinal bleeding in cirrhosis requires immediate initiation of vasoactive drugs, antibiotic prophylaxis, restrictive blood transfusion strategy, and early endoscopic therapy, followed by appropriate secondary prophylaxis based on patient risk factors. 1

Initial Resuscitation and Stabilization

• Assess airway, breathing, and circulation immediately, with prompt volume replacement using crystalloids to restore and maintain hemodynamic stability 1
• Implement a restrictive transfusion strategy with a hemoglobin threshold of 7 g/dL and target range of 7-9 g/dL to avoid increasing portal pressure and risk of rebleeding 1
• Place at least two large-bore intravenous catheters to facilitate rapid volume expansion 1
• Consider airway protection with endotracheal intubation in patients with massive bleeding or hepatic encephalopathy 1
• Avoid nephrotoxic drugs (aminoglycosides, NSAIDs), large volume paracentesis, beta-blockers, and other hypotensive medications during the acute bleeding episode 1

Pharmacological Management

• Start vasoactive drug therapy immediately upon suspicion of variceal bleeding, even before endoscopic confirmation 1
• Choose one of the following vasoactive agents (to be continued for 3-5 days after endoscopic therapy): 1
  • Terlipressin: 2 mg IV every 4 hours for the first 48 hours, then 1 mg IV every 4 hours thereafter
  • Somatostatin: 250 μg IV bolus followed by continuous infusion of 250 μg/hour (can be increased to 500 μg/hour)
  • Octreotide: 50 μg IV bolus followed by continuous infusion of 50 μg/hour
• Initiate antibiotic prophylaxis immediately and continue for up to 7 days to reduce infection risk, improve bleeding control, and enhance survival 1
  • Ceftriaxone 1 g IV daily is the first choice in patients with decompensated cirrhosis, those on quinolone prophylaxis, or in settings with high quinolone resistance
  • Oral quinolones (norfloxacin 400 mg twice daily) can be used in less advanced cirrhosis 1

Endoscopic Management

• Perform upper endoscopy within 12 hours of admission once hemodynamic stability is achieved 1
• Consider pre-endoscopy erythromycin (250 mg IV, 30-120 minutes before) to improve visibility if no contraindications (QT prolongation) exist 1
• For esophageal varices, perform endoscopic band ligation (EBL) as the preferred endoscopic therapy 1
• For gastric varices, use cyanoacrylate injection or EBL (the latter only for small gastric varices that can be completely suctioned into the ligation device) 1
• Sclerotherapy should only be used when band ligation is not feasible 1

Management of Treatment Failure

• For persistent bleeding or early rebleeding (10-15% of cases), transjugular intrahepatic portosystemic shunt (TIPS) is the rescue therapy of choice 1
• Balloon tamponade can be used as a temporary bridge (maximum 24 hours) in cases of uncontrolled bleeding while awaiting definitive treatment 1
• Consider early pre-emptive covered TIPS (within 24-72 hours) in high-risk patients, such as Child-Pugh class C with score <14 or selected Child-Pugh class B patients with active bleeding 1

Prevention of Complications

• Monitor for and manage hepatic encephalopathy with lactulose or lactitol when it develops 1
• Maintain adequate fluid and electrolyte balance to preserve renal function 1
• Consider short-course proton pump inhibitor therapy after endoscopic band ligation to reduce post-banding ulcer size 1

Secondary Prophylaxis

• Once bleeding is controlled, initiate secondary prophylaxis with non-selective beta-blockers (NSBBs) and/or endoscopic band ligation 1
• Exercise caution with NSBBs in patients with severe or refractory ascites, and avoid high doses 1
• Discontinue NSBBs if systolic blood pressure falls below 90 mmHg or during acute intercurrent conditions (bleeding, sepsis, spontaneous bacterial peritonitis, acute kidney injury) 1
• Consider NSBBs as preferred option when possible as they provide additional beneficial effects beyond lowering portal pressure 1

Monitoring and Follow-up

• Closely monitor for signs of rebleeding, which occurs in approximately 17% of patients within 6 weeks 2
• Schedule repeat endoscopic band ligation sessions at 7-14 day intervals until variceal obliteration, typically requiring 2-4 sessions 1
• After eradication, perform surveillance endoscopy every 3-6 months to evaluate for variceal recurrence 1