What medications should be prescribed to a patient with a history of cirrhotic upper GI (Gastrointestinal) bleed upon discharge and what follow-up care is recommended?

Discharge Medications and Follow-up for Cirrhotic Upper GI Bleed

Discharge Medications

All patients with cirrhotic upper GI bleeding should be discharged on non-selective beta-blockers (NSBBs) for secondary prophylaxis, combined with scheduled endoscopic band ligation sessions. 1, 2

Beta-Blocker Therapy

• Initiate non-selective beta-blockers (propranolol or carvedilol) once bleeding is controlled and the patient is hemodynamically stable to prevent rebleeding and reduce portal pressure. 1, 2

• Titrate beta-blockers to achieve a resting heart rate of 55-60 beats per minute or a 25% reduction from baseline, while monitoring for hypotension. 2

• Use beta-blockers with extreme caution in patients with severe or refractory ascites, as they may worsen renal perfusion and outcomes in this population. 1, 2

• Discontinue beta-blockers immediately if systolic blood pressure falls below 90 mmHg or during acute intercurrent conditions such as infection or acute kidney injury. 1, 2

Antibiotic Prophylaxis Duration

• Complete the full 7-day course of antibiotic prophylaxis (ceftriaxone 1g IV daily or ciprofloxacin 1g/day orally) that was initiated during hospitalization, as this reduces infection rates, bacteremia, spontaneous bacterial peritonitis, and improves short-term survival by approximately 9%. 3

Additional Medications to Consider

• Proton pump inhibitors (PPIs) may be prescribed short-term after endoscopic band ligation to reduce post-banding ulcer size, though this is not universally required. 2

• Lactulose or lactitol should be continued or initiated if hepatic encephalopathy developed during hospitalization or if the patient has a history of encephalopathy. 1, 2

• Avoid nephrotoxic drugs, NSAIDs, and other medications that may precipitate rebleeding or hepatic decompensation. 2

Follow-up Care

Endoscopic Surveillance

Schedule repeat endoscopic band ligation sessions at 7-14 day intervals until complete variceal obliteration is achieved, typically requiring 2-4 sessions total. 2

• After variceal eradication, perform surveillance endoscopy every 3-6 months to monitor for variceal recurrence. 2

Clinical Follow-up

• Arrange outpatient hepatology follow-up within 1-2 weeks of discharge to reassess liver function, adjust beta-blocker dosing, and evaluate for complications such as hepatic encephalopathy or ascites. 1, 2

• Monitor for signs of rebleeding including melena, hematemesis, hemodynamic instability, or worsening anemia, and instruct patients to seek immediate medical attention if these occur. 1

• Assess liver transplant candidacy in all patients with decompensated cirrhosis who have experienced variceal bleeding, as this represents a sentinel decompensation event with high mortality risk. 3

Laboratory Monitoring

• Check complete blood count, liver function tests, renal function, and coagulation parameters at the first outpatient visit to establish a new baseline after the bleeding episode. 1, 2

• Monitor for complications of beta-blocker therapy including symptomatic hypotension, bradycardia, and worsening renal function, particularly in patients with ascites. 1, 2

Critical Pitfalls to Avoid

• Never discharge patients on beta-blockers without clear instructions about when to hold or discontinue them (systolic BP <90 mmHg, acute illness, severe ascites worsening). 1, 2

• Do not assume all upper GI bleeding in cirrhosis is variceal—up to 30% of cirrhotic patients bleed from non-variceal causes such as peptic ulcers or portal hypertensive gastropathy, which may require different long-term management. 3, 4

• Avoid high-dose beta-blockers in patients with refractory ascites, as this population may experience harm rather than benefit from aggressive beta-blockade. 1, 2