What is the management approach for a patient with cirrhosis (liver scarring) presenting with melena (black stool)?

Management of Black Stool (Melena) in Cirrhosis

Immediately initiate vasoactive drug therapy (terlipressin, somatostatin, or octreotide) and antibiotic prophylaxis (ceftriaxone 1g IV daily) as soon as you suspect variceal bleeding in a cirrhotic patient with melena, even before endoscopic confirmation. 1, 2

Immediate Resuscitation (First 30 Minutes)

Airway, Breathing, Circulation Assessment:

• Secure airway with endotracheal intubation if massive bleeding or hepatic encephalopathy is present 2
• Place two large-bore IV catheters for rapid volume expansion 2
• Begin volume replacement with crystalloids (avoid starch) to restore hemodynamic stability 1
• Use a restrictive transfusion strategy with hemoglobin threshold of 7 g/dL and target range of 7-9 g/dL to avoid increasing portal pressure and rebleeding risk 1, 2

Pharmacological Management (Start Immediately)

Vasoactive Drug Therapy (choose one):

• Terlipressin: 2 mg IV every 4 hours for first 48 hours, then 1 mg every 4 hours 1
• Somatostatin: 250 µg IV bolus, then continuous infusion at 250 µg/hour (can increase to 500 µg/hour) 1
• Octreotide: 50 µg IV bolus, then continuous infusion at 50 µg/hour 1
• Continue vasoactive therapy for 3-5 days after endoscopic treatment 1, 2

Antibiotic Prophylaxis (mandatory):

• Ceftriaxone 1g IV daily for up to 7 days is first-line for decompensated cirrhosis, patients already on quinolone prophylaxis, or settings with high quinolone resistance 1, 2
• Alternative: Norfloxacin 400 mg PO twice daily in less advanced disease without quinolone exposure 1
• Antibiotic prophylaxis reduces infection incidence by >50%, improves bleeding control, and enhances survival 1

Endoscopic Management (Within 12 Hours)

Pre-Endoscopy Preparation:

• Administer erythromycin 250 mg IV 30-120 minutes before endoscopy to improve gastric emptying and visibility (avoid if QT prolongation) 1, 2
• Perform upper endoscopy within 12 hours once hemodynamically stable 1, 2

Endoscopic Therapy:

• Endoscopic band ligation (EBL) is preferred for esophageal varices—more effective than sclerotherapy with fewer adverse effects 1, 2
• For gastric (cardiofundal) varices: use cyanoacrylate injection or EBL (only for small varices that can be fully suctioned) 1, 2
• The combination of endoscopic therapy plus vasoactive drugs is standard of care—superior to either alone 1

Important caveat: Up to 30% of cirrhotic patients with GI bleeding have non-variceal causes (peptic ulcers, portal hypertensive gastropathy, acute esophageal necrosis), so endoscopy is essential for diagnosis 1, 3

Prevention of Complications (Concurrent Management)

Avoid These During Active Bleeding:

• Nephrotoxic drugs (aminoglycosides, NSAIDs) 1, 2
• Large volume paracentesis 1, 2
• Beta-blockers and vasodilators 1, 2

Monitor and Treat:

• Hepatic encephalopathy: use lactulose or lactitol if develops 1, 2
• Renal function: maintain adequate fluid and electrolyte balance 1
• Bacterial infections: present in 20% at admission, develop in >50% overall—independent predictor of bleeding failure and death 1

Management of Treatment Failure (15% of Cases)

If Bleeding Persists or Recurs:

• Transjugular intrahepatic portosystemic shunt (TIPS) is the rescue therapy of choice 1, 2, 4
• Balloon tamponade can serve as temporary bridge while awaiting TIPS 2, 4
• Early pre-emptive TIPS should be considered in high-risk patients: Child-Pugh C with score <14 or selected Child-Pugh B patients with active bleeding at endoscopy 2

Post-Acute Management

Short-term:

• Consider short-course proton pump inhibitor after EBL to reduce post-banding ulcer size 1, 2
• Continue vasoactive drugs for full 3-5 days to prevent early rebleeding 1, 2

Secondary Prophylaxis:

• Initiate non-selective beta-blockers and/or repeat EBL sessions every 7-14 days until variceal obliteration (typically 2-4 sessions) 2
• Use beta-blockers cautiously in severe/refractory ascites; discontinue if systolic BP <90 mmHg 2, 4
• Surveillance endoscopy every 3-6 months after eradication to monitor for recurrence 2

Critical pitfall: The 2022 EASL guidelines emphasize that for portal hypertension-related bleeding (including portal hypertensive gastropathy), portal pressure-lowering measures are the mainstay—correction of coagulation abnormalities with FFP or platelets is NOT indicated and should only be considered case-by-case if local measures fail 1