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 for variceal bleeding and admitted to the hospital immediately, despite currently normal vital signs and apparent cessation of bleeding. 1

Rationale for Admission and Treatment

Patients with cirrhosis and suspected acute variceal hemorrhage require admission to an intensive care unit setting for resuscitation and management, regardless of current hemodynamic stability. 1 The brief episode of hematemesis in a patient with known cirrhosis and esophageal varices represents acute variceal hemorrhage until proven otherwise, and this carries a mortality risk of 15-20% even with optimal treatment. 2

Critical Points Against Discharge:

• Variceal bleeding has a 60% rebleeding risk within the first year, with early rebleeding (within 5 days) occurring in 10-20% of cases despite treatment. 1, 2
• Normal vital signs do not exclude significant ongoing or imminent rebleeding—hemodynamic stability can be deceptive in cirrhotic patients who may decompensate rapidly. 1
• The mortality from variceal rebleeding reaches 33%, making prevention of early rebleeding a critical priority. 1

Immediate Management Algorithm

1. Initiate Vasoactive Drug Therapy Immediately

Vasoactive drugs should be started as soon as variceal hemorrhage is suspected, even before endoscopic confirmation. 1 This is a Class I, Level A recommendation that takes priority over diagnostic procedures.

Drug options (in order of preference where available): 1

• Terlipressin: 2 mg IV every 4 hours for first 48 hours, then 1 mg every 4 hours (preferred agent—only vasoactive drug proven to improve survival) 1, 2
• Somatostatin: 250 µg bolus, then 250-500 µg/hour continuous infusion 1
• Octreotide: 50 µg bolus, then 50 µg/hour continuous infusion 1

Continue vasoactive therapy for 3-5 days to prevent early rebleeding. 1

2. Antibiotic Prophylaxis

Start antibiotics immediately—this is mandatory in all cirrhotic patients with GI bleeding, as it reduces bacterial infections, decreases rebleeding, and improves survival. 1

Antibiotic choice: 1

• Ceftriaxone 1 g IV daily for up to 7 days (first-line, especially in centers with quinolone resistance or in advanced cirrhosis)
• Norfloxacin 400 mg PO twice daily for 7 days (alternative if ceftriaxone unavailable)

Bacterial infections occur in >50% of cirrhotic patients with GI bleeding and are independent predictors of failure to control bleeding and death. 1

3. Resuscitation Strategy

Use restrictive transfusion strategy with hemoglobin threshold of 7 g/dL and target of 7-9 g/dL. 1 Aggressive resuscitation increases portal pressure, precipitates rebleeding, and worsens mortality. 1

• Avoid vigorous saline resuscitation—this can worsen ascites and precipitate recurrent hemorrhage 1
• Consider airway protection via intubation if there is risk of aspiration, active bleeding, or hepatic encephalopathy 1

4. Endoscopy Within 12 Hours

Perform EGD within 12 hours of admission once hemodynamically stable to confirm variceal source and provide endoscopic band ligation (EBL). 1

• Administer erythromycin 250 mg IV 30-120 minutes before endoscopy to improve visualization (if no QT prolongation contraindication) 1, 3
• EBL is the endoscopic treatment of choice for esophageal varices 1, 3
• Sclerotherapy is acceptable only if EBL is technically not feasible 1

5. Risk Stratification for Early TIPS

In high-risk patients (Child-Pugh C ≤13 or Child-Pugh B with active bleeding at endoscopy), consider preemptive TIPS within 72 hours (ideally <24 hours). 1, 3 This approach markedly decreases rebleeding and improves survival in this subset. 2

Why Other Options Are Incorrect

24-hour observation alone is inadequate: This patient requires active treatment with vasoactive drugs and antibiotics, not just observation. 1

Checking INR for discharge decision is inappropriate: Coagulopathy is common in cirrhosis and does not determine stability for discharge. The risk of rebleeding mandates admission regardless of INR. 1

Discharge because bleeding has stopped is dangerous: Apparent cessation of bleeding does not eliminate the 10-20% risk of early rebleeding within 5 days, which carries 33% mortality. 1, 2

Common Pitfalls to Avoid

• Do not wait for endoscopy to start vasoactive drugs—begin immediately upon suspicion 1
• Do not discharge based on normal vital signs—hemodynamic stability is temporary and deceptive in variceal bleeding 1
• Do not forget antibiotic prophylaxis—this is as important as vasoactive therapy for improving outcomes 1
• Do not over-resuscitate—maintain hemoglobin at 7-9 g/dL, not higher 1