What is the initial management for a patient with cirrhosis (liver scarring) and portal hypertension experiencing an upper gastrointestinal (GI) bleed?

Management of Cirrhotic Upper GI Bleed

In patients with cirrhosis presenting with upper GI bleeding, immediately initiate vasoactive drugs (terlipressin, octreotide, or somatostatin) and antibiotic prophylaxis before endoscopy, followed by urgent endoscopic band ligation within 12 hours once hemodynamically stable, using a restrictive transfusion strategy with hemoglobin target of 7-9 g/dL. 1, 2

Immediate Resuscitation and Initial Management

Hemodynamic Stabilization

• Establish large-bore IV access with at least two 16-gauge peripheral cannulae for rapid volume expansion 3
• Resuscitate with crystalloids to restore hemodynamic stability, avoiding excessive fluid administration that increases portal pressure 1, 2
• Implement restrictive transfusion strategy with hemoglobin threshold of 7 g/dL and target range of 7-9 g/dL to prevent increased portal pressure and rebleeding risk 1, 2
• Cross-match 6 units of blood for availability 3

Airway Protection

• Consider elective intubation for airway protection in patients with: 3
  • Severe uncontrolled variceal bleeding
  • Severe hepatic encephalopathy
  • Inability to maintain oxygen saturation above 90%
  • Aspiration pneumonia or massive bleeding 1

Monitoring

• Transfer to a unit with hemodynamic monitoring capabilities where personnel are experienced in managing variceal bleeding 3
• Establish central venous access for monitoring 3

Pharmacological Therapy (Start Immediately)

Vasoactive Drugs

• Initiate vasoactive therapy immediately upon suspicion of variceal bleeding, even before endoscopic confirmation 1, 2, 4
• Options include: 1, 2
  • Terlipressin (preferred where available)
  • Octreotide
  • Somatostatin
• Continue for 3-5 days after endoscopic therapy 1

Antibiotic Prophylaxis

• Start antibiotics immediately and continue for up to 7 days to reduce infection risk, improve bleeding control, and enhance survival 1, 2
• Ceftriaxone 1g IV daily is first choice in: 1
  • Patients with decompensated cirrhosis
  • Those on quinolone prophylaxis
  • Settings with high quinolone resistance

Medications to Avoid

• Discontinue nephrotoxic drugs, beta-blockers, and other hypotensive medications during the acute bleeding episode 1
• Avoid large volume paracentesis during active bleeding 1

Coagulation Management

Blood Product Administration

• Do NOT routinely correct coagulation parameters (PT, INR, platelet count) with FFP, platelets, or factor concentrates if hemostasis is achieved with endoscopic and pharmacological treatment 3
• Avoid tranexamic acid in patients with cirrhosis and active variceal bleeding (associated with increased venous thromboembolic events without benefit) 3
• Consider viscoelastic testing when available to guide blood product use and reduce unnecessary transfusions 3
• If bleeding control fails, correction of hemostasis should be considered on a case-by-case basis 3

Endoscopic Management

Timing and Preparation

• Perform upper endoscopy within 12 hours of admission once hemodynamic stability is achieved 3, 1, 2
• Consider pre-endoscopy erythromycin (250 mg IV, 30-120 minutes before) to improve gastric emptying and visibility if no contraindications exist 1

Endoscopic Therapy

• Variceal band ligation (EBL) is the method of first choice for esophageal varices 3, 1, 2
• If banding is difficult due to continued bleeding or technique unavailable, perform endoscopic variceal sclerotherapy 3
• For gastric varices, use cyanoacrylate injection or EBL 1

If Endoscopy Unavailable

• Use vasoconstrictors (octreotide or terlipressin) or insert a Sengstaken-Blakemore tube (with adequate airway protection) while arranging definitive therapy 3

Management of Treatment Failure

Rescue Therapy

• TIPS (transjugular intrahepatic portosystemic shunt) is the rescue therapy of choice for persistent bleeding or early rebleeding 1, 2
• Balloon tamponade can be used as a temporary bridge in uncontrolled bleeding while awaiting TIPS or surgical treatment 3, 1, 2

Early Pre-emptive TIPS

• Consider early pre-emptive covered TIPS within 24-72 hours in high-risk patients: 3, 1
  • Child-Pugh class C patients with score <14
  • Child-Pugh class B patients with active bleeding at endoscopy
• This approach reduces mortality in selected high-risk patients 3

Salvage TIPS

• Emergency TIPS (salvage TIPS) should be considered for variceal bleeding refractory to endoscopic treatment, achieving hemostasis in approximately 80% of cases 3

Surgical Options

• If TIPS unavailable or contraindicated, consider surgical intervention such as esophageal transection based on local expertise 3
• Seek specialist help and consider transfer to a specialist center when bleeding is difficult to control 3

Prevention and Management of Complications

Hepatic Encephalopathy

• Monitor for and manage hepatic encephalopathy with lactulose or lactitol when it develops 1, 2

Renal Function

• Maintain adequate fluid and electrolyte balance to preserve renal function 1
• Address contributing factors including renal failure, infection/sepsis, and anemia 3

Post-Procedure Care

• Short-course proton pump inhibitor therapy can be considered after endoscopic band ligation to reduce post-banding ulcer size 1

Secondary Prophylaxis

Initiation

• Begin secondary prophylaxis with non-selective beta-blockers (NSBBs) and/or endoscopic band ligation once bleeding is controlled 1, 2

Beta-Blocker Considerations

• Use NSBBs with caution in patients with severe or refractory ascites, avoiding high doses 1, 2
• Discontinue NSBBs if systolic blood pressure falls below 90 mmHg or during acute intercurrent conditions 1, 2

Endoscopic Follow-up

• Schedule repeat EBL sessions at 7-14 day intervals until variceal obliteration, typically requiring 2-4 sessions 1
• After eradication, perform surveillance endoscopy every 3-6 months to evaluate for variceal recurrence 1

Common Pitfalls to Avoid

• Over-transfusion: Excessive blood product administration increases portal pressure and worsens outcomes; adhere strictly to restrictive transfusion thresholds 1, 2
• Routine coagulation correction: Prophylactic FFP/platelet transfusion is not indicated and may be harmful 3
• Delayed vasoactive therapy: Start immediately upon suspicion, not after endoscopic confirmation 1, 2
• Omitting antibiotics: Antibiotic prophylaxis is critical for reducing mortality and should never be omitted 1, 2
• Continuing beta-blockers during acute bleeding: These worsen hypotension and should be held 1