What is the preferred steroid, dose, and route of administration for a 60-year-old, 60kg man with liver cirrhosis, upper gastrointestinal (GI) bleed, and portal hypertension, who is experiencing a major emergency?

Steroid Management in Cirrhotic Patient with Upper GI Bleed and Shock

In this critically ill cirrhotic patient with upper GI bleeding, steroids should NOT be routinely administered unless the patient develops refractory septic shock requiring high-dose vasopressors, in which case hydrocortisone 50 mg IV every 6 hours (or 200 mg continuous infusion) should be given for up to 7 days or until ICU discharge. 1

Primary Management Priorities (No Steroids Indicated)

The immediate management of this patient centers on controlling the variceal hemorrhage and preventing complications—steroids play no role in this acute phase:

Immediate Resuscitation and Hemostasis

• Initiate vasoactive drugs immediately (octreotide, somatostatin, or terlipressin) even before endoscopic confirmation of variceal bleeding, continuing for 2-5 days after hemostasis 1, 2

• Use balanced crystalloids (lactated Ringer's) for initial volume resuscitation with a restrictive strategy—avoid over-resuscitation as excessive fluid increases portal pressure and rebleeding risk 1, 2, 3

• Maintain restrictive transfusion threshold with hemoglobin target of 7-9 g/dL unless active hemorrhage, myocardial ischemia, or severe hypoxemia present 2, 3

• Administer antibiotic prophylaxis immediately with ceftriaxone 1g IV every 24 hours for up to 7 days—this reduces mortality, bacterial infections, and rebleeding episodes 1, 2

• Perform urgent endoscopy within 12 hours once hemodynamically stable for variceal band ligation 1

Hemodynamic Support Without Steroids

• Use norepinephrine as first-line vasopressor if hypotension persists despite appropriate fluid resuscitation, targeting mean arterial pressure ≥65 mmHg 1

• Add vasopressin as second-line agent when increasing doses of norepinephrine are required 1

• Implement invasive hemodynamic monitoring (arterial and central venous catheter) for adequate assessment and titration 1

When Steroids ARE Indicated: Refractory Septic Shock Only

Hydrocortisone should be considered ONLY if the patient develops refractory shock requiring high-dose vasopressors, based on the ADRENAL and APROCCHSS trials showing earlier shock reversal and potential mortality benefit 1:

Specific Steroid Protocol for Refractory Shock

• Dose: Hydrocortisone 50 mg IV every 6 hours OR 200 mg continuous IV infusion 1

• Duration: Continue for 7 days or until ICU discharge 1

• Indication: Refractory shock requiring high-dose vasopressors despite adequate fluid resuscitation and first-line vasopressor therapy 1

• Consider screening for adrenal insufficiency or empiric trial if shock remains refractory 1

Critical Rationale Against Routine Steroid Use

The 2018 EASL guidelines explicitly state that hydrocortisone treatment of relative adrenal insufficiency (RAI) cannot be recommended in stable cirrhotic patients 1. While RAI affects up to 68.9% of critically ill cirrhotic patients with sepsis, studies show conflicting results:

• One study showed higher rates of shock resolution and survival with hydrocortisone in septic cirrhotic patients 1

• However, a randomized trial found no difference in 28-day mortality, and the hydrocortisone group experienced more shock relapse and GI bleeding 1

Important Pharmacologic Consideration

If steroids become necessary, use prednisolone rather than prednisone in patients with severely impaired liver function, as cirrhotic patients have impaired conversion of prednisone to the active prednisolone 4. However, this distinction is less relevant since hydrocortisone (not prednisone/prednisolone) is the recommended agent for shock 1.

Critical Pitfalls to Avoid

• Do NOT use steroids routinely for upper GI bleeding or portal hypertension—they increase GI bleeding risk and provide no benefit 1

• Avoid over-resuscitation with crystalloids—excessive volume worsens portal pressure, coagulopathy, and rebleeding risk 2, 3

• Do NOT delay vasoactive drugs waiting for endoscopy—start immediately when variceal bleeding is suspected 1, 2

• Never use hydroxyethyl starch for resuscitation—it increases mortality compared to balanced crystalloids 3

• Do NOT transfuse FFP to correct INR in the absence of active bleeding—it fails to correct coagulopathy and worsens portal hypertension 3

Albumin Considerations (Not Steroids)

While not a steroid, albumin 1.5 g/kg on day 1 and 1 g/kg on day 3 should be administered if spontaneous bacterial peritonitis develops, as this improves survival and reduces renal impairment 1, 3. Albumin may also be considered for resuscitation in septic shock with cirrhosis based on single-center RCTs showing improved shock reversal 3.