What medication should be started for a patient with a history of esophageal varices, who had a recent esophagogastroduodenoscopy (EGD) 4 months ago showing no varices, and now presents with melena?

Immediate Management of Suspected Variceal Rebleeding

Start a vasoactive drug (octreotide preferred in the US) immediately upon suspicion of variceal bleeding, even before endoscopy, along with prophylactic antibiotics and blood transfusion support targeting hemoglobin of 7-8 g/dL. 1

Initial Pharmacological Therapy

Vasoactive Drugs - Start Immediately

The cornerstone of acute management is immediate initiation of vasoactive therapy as soon as variceal hemorrhage is suspected, preferably before diagnostic endoscopy. 1, 2

Octreotide is the vasoactive drug of choice in the United States based on its superior safety profile: 1

• Dosing: 50 mcg IV bolus, followed by continuous infusion at 50 mcg/hour 1
• Duration: Continue for 2-5 days after bleeding control 1
• Additional IV boluses can be given if ongoing bleeding occurs 1

Alternative vasoactive agents (if octreotide unavailable): 1, 3

• Terlipressin: 2 mg IV every 4 hours for initial 48 hours, then 1 mg IV every 4 hours (most effective outside US, recently FDA-approved but primarily for HRS) 1, 4
• Somatostatin: 250 mcg IV bolus, followed by 250-500 mcg/hour continuous infusion 1

Antibiotic Prophylaxis - Mandatory

Short-term antibiotic prophylaxis (maximum 7 days) must be started immediately in any cirrhotic patient with GI hemorrhage: 1, 2

First-line options:

• Norfloxacin: 400 mg orally twice daily 1, 2
• Ciprofloxacin: IV formulation if oral administration not possible 1

In advanced cirrhosis or quinolone-resistant areas:

• Ceftriaxone: 1 g IV daily (preferred in centers with high quinolone resistance) 1, 2

Resuscitation Strategy

Blood Transfusion Protocol

• Target hemoglobin: 7-8 g/dL using restrictive transfusion strategy 1
• Careful intravascular volume support to avoid overtransfusion 1
• Maintaining lower hemoglobin reduces rebleeding risk by avoiding increased portal pressure 1

Diagnostic and Therapeutic Endoscopy

Perform EGD within 12 hours once hemodynamically stabilized: 1, 2

• Confirms diagnosis of variceal versus non-variceal bleeding 1
• Stop vasoactive drugs if non-variceal source identified 1
• Endoscopic variceal ligation (EVL) is the preferred endoscopic treatment 1, 2

Post-Endoscopy Adjunct

Consider adding a proton pump inhibitor (pantoprazole 40 mg IV, then 40 mg daily for 9 days) after EVL to reduce post-ligation ulcer size and bleeding risk 1

Clinical Context and Pitfalls

Important Considerations for This Patient

Despite no varices seen 4 months ago, variceal rebleeding remains the most likely diagnosis given the history of previous varices and cirrhosis. 1 Varices can recur rapidly, and melena in a cirrhotic patient should be treated as variceal bleeding until proven otherwise. 1

Common pitfalls to avoid:

• Delaying vasoactive drug initiation until after endoscopy - this significantly worsens outcomes 1, 2
• Overtransfusion above hemoglobin 8 g/dL increases portal pressure and rebleeding risk 1
• Forgetting antibiotic prophylaxis - this is a Class I, Level A recommendation that reduces mortality 1
• Stopping vasoactive drugs too early - continue for minimum 2 days, preferably 3-5 days 1

Duration of Vasoactive Therapy

While guidelines recommend 2-5 days, you can consider shortening to 2 days only in highly selected patients with Child-Pugh class A or B cirrhosis who have no active bleeding at endoscopy. 1 However, given this patient's history and presentation, plan for the full 3-5 day course. 1

Rescue Therapy if Initial Management Fails

If bleeding persists or recurs despite combined pharmacological and endoscopic therapy (occurs in 10-20% of cases): 1, 2

• TIPS (transjugular intrahepatic portosystemic shunt) is indicated as rescue therapy 1
• Balloon tamponade as temporary bridge (maximum 24 hours) while arranging definitive therapy 1