What is the initial management for a patient with cirrhosis (scarring of the liver) presenting with an upper gastrointestinal (GI) bleed?

Management of Upper GI Bleed in Cirrhosis

Start vasoactive drugs (terlipressin, somatostatin, or octreotide) and antibiotic prophylaxis immediately upon suspicion of upper GI bleeding in cirrhotic patients, even before endoscopic confirmation. 1, 2

Immediate Resuscitation (First Hour)

Airway, Breathing, Circulation

• Secure airway with endotracheal intubation if massive bleeding or hepatic encephalopathy is present to prevent aspiration 2
• Place two large-bore IV catheters for rapid volume expansion 2
• Resuscitate with crystalloids (or colloids) to restore hemodynamic stability, avoiding excessive fluid that increases portal pressure 1, 2

Restrictive Transfusion Strategy

• Transfuse packed red blood cells only when hemoglobin falls below 7 g/dL, targeting 7-9 g/dL 1, 2, 3
• This restrictive approach prevents increased portal pressure and reduces rebleeding risk 1
• Avoid over-transfusion as it worsens portal hypertension 2

Medications to Avoid

• Stop beta-blockers, nephrotoxic drugs, and other hypotensive medications during acute bleeding 2
• Avoid large volume paracentesis during the bleeding episode 2

Pharmacological Management (Within Minutes)

Vasoactive Drugs (Start Immediately)

Initiate vasoactive therapy as soon as variceal bleeding is suspected, before endoscopy 1, 2

Choose one of the following regimens:

• Terlipressin: 2 mg IV every 4 hours for first 48 hours, then 1 mg IV every 4 hours 1
• Somatostatin: 250 µg IV bolus, then 250 µg/hour continuous infusion (can increase to 500 µg/hour) 1
• Octreotide: 50 µg IV bolus, then 50 µg/hour continuous infusion 1

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

Antibiotic Prophylaxis (Start Immediately)

Administer antibiotics immediately upon presentation, before endoscopy 1, 2

• Ceftriaxone 1 g IV daily is first-line for up to 7 days in decompensated cirrhosis, patients on quinolone prophylaxis, or areas with high quinolone resistance 1, 2
• Alternative: Norfloxacin orally if ceftriaxone unavailable 1
• Antibiotic prophylaxis reduces infection rates (which occur in >50% of patients), improves bleeding control, and reduces mortality 1
• Bacterial infections independently predict failure to control bleeding and death 1

Note: Recent data suggests 3 days of antibiotics may be adequate if no active infection develops, though guidelines still recommend up to 7 days 4

Endoscopic Management (Within 12 Hours)

Timing and Preparation

• Perform upper endoscopy within 12 hours of admission once hemodynamic stability is achieved 1, 2
• This timing allows for adequate resuscitation while enabling early diagnosis and treatment 1
• Consider erythromycin 250 mg IV 30-120 minutes before endoscopy to improve gastric emptying and visibility, unless QT prolongation present 1, 2

Endoscopic Therapy

• Endoscopic band ligation (EBL) is the preferred treatment for esophageal varices 1, 2, 3
• EBL is more effective than sclerotherapy with fewer adverse effects 1
• For gastric (cardiofundal) varices: use cyanoacrylate injection or EBL (EBL only for small varices that can be fully suctioned) 1, 2
• Combining endoscopic therapy with vasoactive drugs is more effective than either alone and represents standard of care 1

Important Caveat

• Up to 30% of cirrhotic patients bleed from non-variceal causes (peptic ulcer, portal hypertensive gastropathy, etc.), making endoscopy essential for diagnosis 1

Management of Treatment Failure

Salvage TIPS (Rescue Therapy)

If bleeding persists despite endoscopic and medical therapy (refractory bleeding occurring in ~15% of cases): 1

• Emergency TIPS with covered stent can control bleeding in 80% of refractory cases 1
• Balloon tamponade (Blakemore tube) or self-expandable esophageal stent can serve as temporary bridge to TIPS 1, 2

Early Pre-emptive TIPS (Within 24-72 Hours)

Consider early TIPS in high-risk patients: 1, 2

• Child-Pugh class C with score <14 1, 2
• Child-Pugh class B with active bleeding at initial endoscopy 1, 2
• Early TIPS in these populations reduces mortality at 2 years 1

Prevention of Complications (Concurrent Management)

Infection Prevention

• Bacterial infections occur in >50% of patients and may precipitate bleeding 1
• Monitor for spontaneous bacterial peritonitis, aspiration pneumonia, and bacteremia 1
• Antibiotic prophylaxis addresses this critical complication 1

Hepatic Encephalopathy

• Monitor for and treat hepatic encephalopathy with lactulose or lactitol 2, 3
• Encephalopathy commonly develops during bleeding episodes 1

Renal Function

• Maintain adequate fluid and electrolyte balance to preserve renal function 2
• Avoid nephrotoxic agents 2
• Renal deterioration is a common complication that worsens prognosis 1

Hemostatic Management

Blood Product Transfusion

Do NOT routinely transfuse fresh frozen plasma, platelets, or fibrinogen concentrates prophylactically before procedures 1

• Conventional coagulation tests (INR, platelet count) do not predict procedural bleeding in cirrhosis 1
• Cirrhotic patients maintain balanced hemostasis despite abnormal lab values 1
• Consider viscoelastic tests (TEG/ROTEM) when available to guide transfusion decisions in actively bleeding patients 1

Secondary Prophylaxis (After Bleeding Controlled)

Long-term Management

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

Key Pitfalls to Avoid

1. Delaying vasoactive drugs until endoscopy - Start immediately on suspicion 1
2. Over-transfusing blood products - Increases portal pressure and rebleeding 1, 2
3. Continuing beta-blockers during acute bleeding - Worsens hypotension 2
4. Prophylactic FFP/platelet transfusion - Not indicated and lacks evidence 1
5. Missing the 12-hour endoscopy window - Delays definitive diagnosis and therapy 1
6. Failing to identify high-risk patients for early TIPS - Child C <14 or Child B with active bleeding benefit from early intervention 1, 2