What is the immediate management for a patient with chronic liver disease (CLD) presenting with an acute upper gastrointestinal (GI) bleed?

Critical Care Management of Acute Upper GI Bleed in Chronic Liver Disease

Immediate Resuscitation (First 30 Minutes)

Initiate vasoactive drug therapy immediately upon suspicion of variceal bleeding, even before endoscopic confirmation, as this is the single most critical intervention to reduce mortality. 1

Airway, Breathing, Circulation

• Airway protection: Intubate patients with massive hematemesis, altered mental status, or hepatic encephalopathy to prevent aspiration 2
• Vascular access: Place two large-bore IV catheters (18-gauge or larger) in the anticubital fossae for rapid volume expansion 1, 2
• Volume resuscitation: Administer crystalloids (normal saline or balanced crystalloids) to restore hemodynamic stability, targeting systolic BP >100 mmHg, heart rate <100 bpm, and urine output >30 mL/hour 1, 3

Restrictive Transfusion Strategy

• Transfuse packed red blood cells only when hemoglobin falls below 7 g/dL, with a target range of 7-9 g/dL 1, 3
• This restrictive approach prevents increased portal pressure and reduces rebleeding risk compared to liberal transfusion 1, 4
• In patients with active massive bleeding or severe cardiac disease, transfusion at hemoglobin <8 g/dL is acceptable 1

Pharmacological Management (Within First Hour)

Vasoactive Drugs (Start Immediately)

Begin vasoactive therapy as soon as variceal bleeding is suspected, before endoscopy. The following options are equally effective 1:

• Octreotide: 50 mcg IV bolus, then 50 mcg/hour continuous infusion 1
• Somatostatin: 250 mcg IV bolus, then 250-500 mcg/hour continuous infusion 1
• Terlipressin: 2 mg IV every 4 hours for 48 hours, then 1 mg every 4 hours 1, 4

Continue vasoactive therapy for 3-5 days after endoscopic treatment to prevent early rebleeding 1, 2

Antibiotic Prophylaxis (Start Immediately)

• Ceftriaxone 1 g IV daily for up to 7 days is the first-line antibiotic in patients with decompensated cirrhosis, those on quinolone prophylaxis, or in areas with high quinolone resistance 1, 2, 4
• Alternative: Norfloxacin 400 mg PO twice daily in less severe cases 1
• Antibiotic prophylaxis reduces infection rates by >50%, improves bleeding control, and reduces mortality 1, 5

Proton Pump Inhibitors

• Administer high-dose PPI (e.g., pantoprazole 80 mg IV bolus, then 8 mg/hour infusion) in all patients with upper GI bleeding 1, 6
• PPIs are particularly important for non-variceal bleeding and post-endoscopic band ligation ulcer prevention 2

Risk Stratification

Assess severity using clinical parameters and Child-Pugh score 3, 4:

• High-risk features: Child-Pugh C (score ≤13), Child-Pugh B with active bleeding at endoscopy, MELD >18, systolic BP <100 mmHg, heart rate >100 bpm, hemoglobin <7 g/dL 3, 4
• Liver failure adds 3 points to Rockall score, indicating significantly higher mortality risk 3

Endoscopic Management (Within 12 Hours)

Pre-Endoscopy Preparation

• Administer erythromycin 250 mg IV 30-120 minutes before endoscopy to improve gastric emptying and visualization, unless contraindicated by QT prolongation 1, 2, 4
• Perform endoscopy within 12 hours of presentation once hemodynamic stability is achieved 1, 2, 4

Endoscopic Therapy

• Esophageal varices: Endoscopic band ligation (EBL) is the treatment of choice 1, 2, 4
• Gastric varices (GOV2, IGV1): Cyanoacrylate injection is preferred 1, 4
• GOV1 varices: Either EBL or cyanoacrylate injection 4
• Sclerotherapy only if band ligation is technically not feasible 1

Management of Refractory or Recurrent Bleeding

Rescue Therapy

For persistent bleeding despite medical and endoscopic therapy, transjugular intrahepatic portosystemic shunt (TIPS) is the definitive rescue treatment. 1, 2, 4

• Pre-emptive TIPS: Consider within 24-72 hours in high-risk patients (Child-Pugh C score <14 or Child-Pugh B >7 with active bleeding at endoscopy) 2, 4, 6
• Rescue TIPS: For treatment failure or early rebleeding (within 5 days) 1, 2

Temporary Bridge Therapy

• Balloon tamponade (Sengstaken-Blakemore or Minnesota tube) can be used for up to 24 hours as a bridge to TIPS or definitive therapy in uncontrolled bleeding 3, 2
• Self-expanding metal stents (SEMS) achieve 91% immediate bleeding control and can serve as an alternative bridge therapy, though with 18% migration risk 7

Prevention of Complications

Hepatic Encephalopathy

• Monitor for altered mental status and initiate lactulose 30 mL PO/NG every 2-4 hours (titrate to 2-3 soft stools daily) if encephalopathy develops 3, 2
• Rifaximin 550 mg PO twice daily can be added as adjunctive therapy 1

Renal Protection

• Avoid nephrotoxic drugs, NSAIDs, and aminoglycosides 2
• Do NOT perform large-volume paracentesis during acute bleeding 1, 2
• Monitor urine output hourly via Foley catheter in severe bleeding 1

Medication Adjustments

• Discontinue beta-blockers during acute bleeding episode to avoid hypotension 2
• Hold diuretics until hemodynamic stability is restored 2

Secondary Prophylaxis (After Bleeding Control)

• Initiate non-selective beta-blockers (carvedilol preferred, or propranolol/nadolol) combined with repeat EBL sessions 2, 4
• Schedule EBL every 1-4 weeks until variceal eradication (typically 2-4 sessions) 2, 4
• Surveillance endoscopy every 3-6 months after eradication to detect recurrence 2, 4

Common Pitfalls to Avoid

• Do NOT delay vasoactive drugs waiting for endoscopy - start immediately on clinical suspicion 1
• Do NOT over-transfuse - liberal transfusion increases portal pressure and rebleeding 1, 3
• Do NOT perform endoscopy before adequate resuscitation - this increases procedural complications 1
• Do NOT forget antibiotic prophylaxis - infections occur in >50% without prophylaxis and worsen outcomes 1, 5
• Do NOT continue beta-blockers during acute bleeding - they worsen hypotension 2