What is the management of a gastrointestinal (GI) bleed in a patient with cirrhosis?

Management of GI Bleeding in Cirrhosis

The management of gastrointestinal bleeding in patients with cirrhosis requires immediate implementation of a comprehensive algorithm focusing on resuscitation, pharmacological therapy, endoscopic intervention, and prevention of complications to reduce mortality and morbidity. 1

Initial Resuscitation and Stabilization

• Assess circulatory status immediately and establish adequate vascular access with two large-bore peripheral IV cannulae or central venous access for fluid resuscitation 2
• Implement a restrictive red blood cell 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, 2
• Consider tracheal intubation for patients with active hematemesis, inability to maintain airway, or when optimal sedation is needed for endoscopic examination 2
• Avoid nephrotoxic drugs, large volume paracentesis, beta-blockers, and other hypotensive medications during the acute bleeding episode 1

Pharmacological Management

• Initiate vasoactive drug therapy immediately upon suspicion of variceal bleeding, even before endoscopic confirmation 1
• Administer octreotide with an initial IV bolus of 50 μg (can be repeated in first hour if ongoing bleeding), followed by continuous IV infusion of 50 μg/h for 2-5 days 2
• Start antibiotic prophylaxis immediately with IV ceftriaxone 1 g/24 h (maximum duration 7 days) to reduce infections, rebleeding, and mortality 2, 3
• Be cautious with tranexamic acid as it may increase the risk of venous thromboembolic events in patients with cirrhosis 2

Endoscopic Management

• Perform urgent endoscopic assessment within 12 hours of presentation (as soon as possible) after stabilization of circulatory and respiratory status 2, 1
• Consider administration of erythromycin (250 mg IV, 30-120 minutes before emergency endoscopy) to optimize visualization 2, 1
• Use endoscopic band ligation as the preferred therapy for esophageal varices 1
• For gastric varices, use cyanoacrylate injection or endoscopic band ligation 1
• Schedule follow-up endoscopy one month after treatment to ensure resolution of gastric varices 2

Management of Treatment Failure

• For persistent bleeding or early rebleeding, transjugular intrahepatic portosystemic shunt (TIPS) is the rescue therapy of choice 1
• Consider balloon tamponade as a temporary bridge in cases of uncontrolled bleeding while awaiting definitive treatment 1
• For refractory bleeding from portal hypertensive gastropathy, TIPS placement should be considered 2
• For cardiofundal gastric varices, balloon-occluded retrograde transvenous obliteration (BRTO) may be an alternative to TIPS 2

Coagulation Management

• GI bleeding in cirrhosis is primarily precipitated by portal hypertension rather than coagulopathy, so avoid overuse of blood products which can increase portal pressure 2
• There is no specific international normalized ratio or platelet cutoff for procedural bleeding risk, so specific transfusion cutoffs cannot be recommended 2
• In cases of failure to control hemorrhage with portal hypertension-lowering drugs, correction of hemostasis should be considered on a case-by-case basis 2
• Hemostatic drugs have not shown benefit and may be associated with higher rebleeding rates in cirrhotic patients with acute upper GI bleeding 4

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
• Manage patients with acute variceal hemorrhage in an intensive care unit or other well-monitored setting due to the risk for mortality and complexity of care required 2

Secondary Prophylaxis

• Initiate secondary prophylaxis with non-selective beta-blockers (NSBBs) and/or endoscopic band ligation once bleeding is controlled 1
• Use NSBBs with caution in patients with severe or refractory ascites, and discontinue if systolic blood pressure falls below 90 mmHg 1
• For patients with portal hypertensive gastropathy, use beta-blockers for chronic management after the acute bleeding episode 2

Monitoring and Follow-up

• Perform repeat endoscopic band ligation sessions at 7-14 day intervals until variceal obliteration 1
• Conduct surveillance endoscopy every 3-6 months to evaluate for variceal recurrence after eradication 1
• For patients who received TIPS, perform endoscopic examination 1 month after to ensure resolution of gastric varices 2

Special Considerations

• For non-variceal bleeding sources in cirrhosis, address the bleeding first by local measures and/or interventional radiology procedures 2
• In patients with portal hypertensive gastropathy, management should focus on portal pressure-lowering strategies using vasoactive therapy in the acute setting and beta-blockers in the chronic setting 2
• Be aware that the prognosis of digestive bleeding in cirrhosis has improved significantly over the past two decades, with initial treatment stopping bleeding in approximately 90% of patients 5, 6