What is the management of upper gastrointestinal (GI) bleed in patients with chronic liver disease (CLD)?

Management of Upper Gastrointestinal Bleeding in Chronic Liver Disease

In patients with chronic liver disease and upper GI bleeding, immediate resuscitation with crystalloids, restrictive blood transfusion (hemoglobin threshold of 7 g/dL), early administration of vasoactive drugs, and prophylactic antibiotics should be initiated, followed by endoscopic intervention within 12 hours of admission. 1

Initial Assessment and Resuscitation

• Assess airway, breathing, and circulation immediately, with prompt volume replacement using crystalloids to restore hemodynamic stability 1
• Place at least two large-bore intravenous catheters to facilitate rapid fluid resuscitation 1
• Implement a restrictive transfusion strategy (hemoglobin threshold of 7 g/dL, target 7-9 g/dL) to avoid increasing portal pressure and risk of rebleeding 1
• Consider airway protection with endotracheal intubation in patients with massive bleeding or hepatic encephalopathy 1
• Avoid nephrotoxic drugs, large volume paracentesis, beta-blockers, and other hypotensive medications during the acute bleeding episode 1
• Monitor for shock (pulse >100 beats/min, systolic BP <100 mmHg) which indicates severe bleeding 2

Pharmacological Management

• Start vasoactive drug therapy immediately upon suspicion of variceal bleeding, even before endoscopic confirmation 1
• Use terlipressin, somatostatin, or octreotide to reduce splanchnic blood flow and portal pressure, continuing for 3-5 days after endoscopic therapy 2, 1
• Initiate antibiotic prophylaxis immediately and continue for up to 7 days (ceftriaxone 1g IV daily is preferred in decompensated cirrhosis) 1
• Consider proton pump inhibitor infusion over intermittent administration for non-variceal bleeding 2

Risk Assessment

• Evaluate severity of liver disease as prognosis is related more to severity of liver disease than magnitude of hemorrhage 2
• Use the Rockall scoring system to assess risk of rebleeding and death (scores >8 associated with high mortality) 2
• Note that patients with liver failure receive 3 points in the comorbidity section of the Rockall score 2
• Consider viral hepatitis or alcoholic etiology, advanced cirrhosis, decreased liver function, and impaired hemostasis as independent predictors of bleeding 3

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 1
• For esophageal varices, endoscopic band ligation is the preferred treatment 1
• For gastric varices, use cyanoacrylate injection or band ligation 1, 4
• For non-variceal bleeding, endoscopic therapy should be guided by findings (e.g., ulcers with clean base have low rebleeding risk) 2

Management of Treatment Failure

• Use transjugular intrahepatic portosystemic shunt (TIPS) as rescue therapy for persistent bleeding or early rebleeding 1
• Consider balloon tamponade as a temporary bridge in cases of uncontrolled bleeding while awaiting definitive treatment 2, 1
• For massive bleeding with poor visualization, consider temporary placement of a compression tube (Sengstaken-Blakemore or Linton-Nachlas) 2
• Consider early pre-emptive covered TIPS in high-risk patients (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 1
• Maintain adequate fluid and electrolyte balance to preserve renal function 1
• Treat comorbid conditions that may be decompensated by bleeding 2
• Consider short-course proton pump inhibitor therapy after endoscopic band ligation 1

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 1
• Discontinue NSBBs if systolic blood pressure falls below 90 mmHg 1
• Schedule repeat endoscopic band ligation sessions at 7-14 day intervals until variceal obliteration 1
• Perform surveillance endoscopy every 3-6 months after eradication to evaluate for variceal recurrence 1

Special Considerations in CLD

• Recognize that patients with liver disease have prognosis related more to severity of liver disease than to magnitude of hemorrhage 2
• Correct coagulopathy cautiously, aiming for hematocrit >25%, platelet count >50,000, and fibrinogen >120 mg/dl 2
• Manage portal hypertensive gastropathy or ectopic varices with beta blocker therapy, injection therapy, or interventional radiology 4