What is the best next step in managing a patient with a history of cirrhosis and esophageal varices who presents with a brief episode of hematemesis that has since stopped?

Management of Suspected Variceal Hemorrhage in Cirrhosis

This patient must be treated as an acute variceal bleed and admitted to the hospital immediately, even though bleeding appears to have stopped and vital signs are currently stable. 1

Rationale for Admission and Treatment

Patients with cirrhosis and suspected variceal hemorrhage require hospital admission to an intensive care setting regardless of current hemodynamic stability. 1 The mortality risk from variceal bleeding remains 15-20% even with modern treatment, and the rebleeding rate within the first 5 days is 10-20% despite optimal therapy. 2 Apparent cessation of bleeding does not eliminate the risk of life-threatening rebleeding or complications such as bacterial infections (occurring in >50% of cases), hepatic encephalopathy, or renal failure. 1

Immediate Management Steps

Vasoactive Drug Therapy

• Initiate vasoactive drugs immediately upon suspicion of variceal bleeding, even before endoscopic confirmation. 1, 3
• Options include terlipressin (2 mg IV every 4 hours for 48 hours, then 1 mg every 4 hours), somatostatin (250 µg/h continuous infusion), or octreotide (50 µg/h continuous infusion). 1
• Terlipressin is the only vasoactive agent proven to improve survival. 2
• Continue therapy for 3-5 days after diagnosis confirmation to prevent early rebleeding. 1

Antibiotic Prophylaxis

• Administer prophylactic antibiotics to all cirrhotic patients with GI bleeding immediately upon presentation. 1
• Ceftriaxone 1 g IV daily for up to 7 days is the first-line choice, particularly in centers with quinolone-resistant organisms or in patients with advanced cirrhosis. 1
• Alternative: norfloxacin 400 mg PO twice daily for 7 days if oral administration is possible. 1
• Antibiotic prophylaxis reduces bacterial infections, decreases early rebleeding, and improves survival. 1

Resuscitation Strategy

• Use restrictive transfusion strategy: transfuse when hemoglobin drops to ≤7 g/dL, targeting 7-9 g/dL post-transfusion. 1
• Avoid aggressive fluid resuscitation as this increases portal pressure and precipitates rebleeding. 1
• Consider airway protection via elective intubation if there is active bleeding with risk of aspiration or hepatic encephalopathy. 1, 3

Endoscopic Evaluation

• Perform esophagogastroduodenoscopy within 12 hours of admission once hemodynamically stable. 1, 4
• Endoscopic band ligation (EVL) is the treatment of choice if variceal bleeding is confirmed. 1, 4
• Consider erythromycin 250 mg IV 30-120 minutes before endoscopy to improve visualization. 1, 4

Why Other Options Are Incorrect

24-hour observation alone is inadequate because it does not address the high risk of early rebleeding, bacterial infections, or other complications that require specific interventions (vasoactive drugs, antibiotics, endoscopy). 1

Checking INR and discharging if normal is dangerous because coagulopathy is not the primary determinant of variceal bleeding risk. The underlying portal hypertension and risk of rebleeding persist regardless of INR values. 1

Discharging the patient because bleeding has stopped is inappropriate because up to 60% of patients rebleed within 1-2 years without treatment, with early rebleeding (within 5 days) occurring in 10-20% despite optimal therapy. 1, 2 Normal vital signs do not exclude ongoing risk, as cirrhotic patients may not mount appropriate hemodynamic responses. 1

Critical Pitfalls to Avoid

• Never delay vasoactive drug therapy waiting for endoscopic confirmation—start immediately when variceal bleeding is suspected. 1, 3
• Do not withhold antibiotics—they are mandatory in all cirrhotic patients with GI bleeding and improve survival independent of infection presence. 1
• Avoid over-resuscitation—aggressive volume replacement increases portal pressure and worsens outcomes. 1
• Do not discharge based on apparent cessation of bleeding—the highest risk period for rebleeding is the first 5 days. 1, 2