What is the management approach for a patient with chronic liver disease (CLD) presenting with hematemesis and severe anemia (hemoglobin level of 4.7 g/dL)?

Management of Hematemesis in Chronic Liver Disease with Severe Anemia (Hb 4.7 g/dL)

This patient requires immediate resuscitation with crystalloids, restrictive packed red blood cell transfusion starting at Hb <7 g/dL targeting 7-9 g/dL, vasoactive drugs (terlipressin or octreotide), prophylactic antibiotics (ceftriaxone 1g IV daily), and urgent endoscopy within 12 hours once hemodynamically stable. 1, 2

Immediate Resuscitation and Hemodynamic Stabilization

Fluid Resuscitation Strategy

• Initiate crystalloid resuscitation but avoid over-expansion, as excessive volume increases portal pressure, impairs clot formation, and exacerbates bleeding. 1
• A degree of controlled hypotension is actually beneficial, as it activates endogenous vasoconstriction reducing portal blood flow. 1
• Acute hypotension must be avoided as it decreases hepatic perfusion and worsens underlying liver injury. 1

Blood Transfusion Protocol

• Begin packed red blood cell transfusion when hemoglobin drops below 7 g/dL, with a target of 7-9 g/dL. 1, 2
• This restrictive strategy improves survival in Child-Pugh A and B patients compared to liberal transfusion. 1
• For active variceal bleeding, the American Gastroenterology Association suggests maintaining hematocrit >25%, platelet count >50,000, and fibrinogen >120 mg/dL. 1
• Exceptions to restrictive transfusion include massive ongoing bleeding, cardiovascular comorbidities, or inability to mount physiological response to anemia. 1

Correction of Coagulopathy

• Do not routinely correct INR with fresh frozen plasma, as INR does not reliably predict bleeding risk in cirrhosis. 2, 3
• Platelet transfusion is indicated only if count <50,000 and active bleeding continues despite endoscopic/pharmacologic therapy. 1

Pharmacological Management

Vasoactive Drugs (Start Immediately)

• Initiate vasoactive drugs as soon as variceal hemorrhage is suspected, before endoscopy. 1
• Options include terlipressin (preferred) or octreotide to reduce splanchnic blood flow and portal pressure. 1
• Continue for 2-5 days depending on bleeding control and liver disease severity. 1

Antibiotic Prophylaxis

• Administer ceftriaxone 1g IV every 24 hours immediately upon presentation. 1
• Continue for maximum 7 days (consider stopping when bleeding resolves and vasoactive drugs discontinued). 1
• Short-course prophylactic antibiotics are strongly recommended as they reduce bacterial infections and mortality. 1

Beta-Blocker Management

• Temporarily suspend non-selective beta-blockers during acute bleeding episode, as they may worsen hypotension. 1
• Restart after stabilization for secondary prophylaxis. 1

Endoscopic Intervention

Timing and Approach

• Perform esophagogastroduodenoscopy within 12 hours of admission once hemodynamically stable. 1
• If varices confirmed, perform endoscopic variceal ligation immediately. 1
• Vasoactive drugs provide clearer endoscopic field and are the only treatment for non-esophagogastric variceal bleeding. 1

Risk Stratification for Early TIPS

• For high-risk patients (Child-Pugh C or Child-Pugh B with active bleeding on endoscopy), consider early/preemptive TIPS within 72 hours. 1
• This improves survival in selected high-risk patients who constitute <20% of variceal hemorrhage admissions. 1
• Standard therapy patients continue vasoactive drugs for up to 5 days. 1

Rescue Therapy for Refractory Bleeding

Bridge Therapy Options

• If bleeding persists despite combined pharmacological and endoscopic therapy (occurs in up to 20% of cases with high mortality), consider: 1
  • Balloon tamponade (Sengstaken-Blakemore or Linton-Nachlas tube) as temporary bridge until definitive therapy, maximum 24 hours. 1
  • Self-expandable metal stents (superior to balloon tamponade with better bleeding control, fewer side effects, can remain 7 days). 1
  • Rescue TIPS is definitive therapy for refractory bleeding. 1

Management of Underlying Anemia

Identify and Treat Contributing Factors

• Anemia affects 66% of patients with advanced chronic liver disease and is multifactorial. 4
• Evaluate for iron deficiency (most common correctable cause), folate deficiency, vitamin B12 deficiency, and vitamin B6 deficiency. 3, 5, 6
• Iron deficiency occurs in 9% of cases and should be treated with oral or parenteral iron supplementation. 4, 6
• Gastrointestinal bleeding accounts for 25% of anemia in chronic liver disease. 4

Long-term Optimization

• Iron supplementation is a significant predictor of hemoglobin increase and improved transplant-free survival. 3
• Optimize nutritional deficiencies before invasive procedures when possible. 2, 3

Critical Pitfalls to Avoid

• Never use liberal transfusion strategy (threshold 9 g/dL) as it increases portal pressure and worsens outcomes. 2, 3
• Do not rely on INR to guide transfusion decisions in cirrhosis—it does not reflect true coagulation status. 2
• Avoid over-resuscitation with fluids, which exacerbates portal hypertension and bleeding. 1
• Do not delay vasoactive drugs waiting for endoscopy—start immediately when variceal bleeding suspected. 1
• Balloon tamponade should never exceed 24 hours due to high complication rates. 1
• Do not continue beta-blockers during acute bleeding episode as they worsen hypotension. 1