How should I manage an 80‑year‑old man who presented three days after melena and hematemesis and has ultrasound evidence of chronic liver disease with portal hypertension?

Management of Upper GI Bleeding in an 80-Year-Old with Chronic Liver Disease and Portal Hypertension

This patient requires urgent upper endoscopy within 12 hours, immediate initiation of vasoactive drugs (octreotide or terlipressin) and intravenous ceftriaxone, conservative blood transfusion targeting hemoglobin 7-9 g/dL, and endoscopic variceal ligation if varices are confirmed as the bleeding source. 1

Immediate Resuscitation and Medical Therapy

Blood Product Management

• Transfuse packed red blood cells conservatively, starting when hemoglobin reaches 7 g/dL with a target of 7-9 g/dL. 1 This restrictive transfusion strategy improves outcomes in variceal bleeding compared to liberal transfusion, as excessive transfusion increases portal pressure and rebleeding risk.

Antibiotic Prophylaxis

• Initiate intravenous ceftriaxone 1 g every 24 hours immediately for maximum 7 days in any cirrhotic patient with GI hemorrhage. 1 This reduces bacterial infections, spontaneous bacterial peritonitis, and mortality in this high-risk population. 1

Vasoactive Drug Therapy

• Start vasoactive drugs immediately upon suspicion of variceal hemorrhage, before endoscopy. 1 Options include:
  • Octreotide (somatostatin analogue): 50 mcg bolus followed by 50 mcg/hour infusion 1
  • Terlipressin (vasopressin analogue): if available 1
• Continue vasoactive drugs for 2-5 days after endoscopic intervention. 1
• The combination of endoscopic therapy and pharmacological treatment improves hemostasis and reduces mortality. 2

Diagnostic Evaluation

Urgent Upper Endoscopy

• Perform esophagogastroduodenoscopy (EGD) within 12 hours of admission once hemodynamically stable. 1 This timing allows for adequate resuscitation while enabling timely diagnosis and therapeutic intervention.

Endoscopic Findings and Intervention

• If esophageal varices are confirmed or suspected as the bleeding source, perform endoscopic variceal ligation (EVL) during the same procedure. 1
• Assess for other potential bleeding sources including gastric varices, portal hypertensive gastropathy, and peptic ulcer disease. 2

Risk Stratification and Advanced Interventions

High-Risk Patient Identification

This 80-year-old patient presenting 3 days after symptom onset with ultrasound evidence of chronic liver disease requires assessment of:

• Child-Turcotte-Pugh (CTP) class - Class C or Class B with active bleeding on endoscopy identifies high-risk patients. 1
• Active bleeding at endoscopy - indicates increased risk of treatment failure. 1

Early TIPS Consideration

• In high-risk patients (CTP class C or CTP class B with active bleeding on endoscopy) without contraindications, consider "early" or preemptive TIPS within 72 hours of EGD/EVL. 1 This approach significantly improves outcomes in carefully selected high-risk patients.

Rescue TIPS

• If hemorrhage cannot be controlled or bleeding recurs despite vasoactive drugs plus EVL, proceed with rescue TIPS. 1 This represents salvage therapy for refractory variceal bleeding.

Post-Acute Management

Transition to Oral Therapy

• Once vasoactive drugs are discontinued, initiate non-selective beta-blockers (propranolol or nadolol) before hospital discharge. 1 This prevents rebleeding, which occurs in 60% of patients within the first year without prophylaxis. 1

Combination Therapy for Secondary Prophylaxis

• The optimal long-term strategy combines non-selective beta-blockers with scheduled endoscopic variceal ligation. 1 This combination is significantly more effective than EVL alone in preventing recurrent GI hemorrhage. 1

Liver Transplant Evaluation

• Refer all patients with decompensated cirrhosis (including those with variceal bleeding) for liver transplantation evaluation, as this represents definitive treatment. 2 The presence of ascites reduces 5-year survival from 80% to 50% without transplantation. 2

Important Clinical Caveats

Avoid Certain Interventions

• Do not use transjugular intrahepatic portosystemic shunt (TIPS) for routine portal hypertension management in hereditary hemorrhagic telangiectasia or similar vascular malformation syndromes, as it may worsen the hyperdynamic circulatory state. 1
• Beta-blockers should be avoided in portopulmonary hypertension if present, as they worsen hemodynamics and exercise capacity. 1

Anticoagulation Considerations

• Oral anticoagulation is generally not recommended in patients with portal hypertension due to cirrhosis given elevated bleeding risk. 1 However, if portal vein thrombosis with intestinal ischemia is suspected, urgent anticoagulation is required. 1

Fluid Restriction

• Fluid restriction is not necessary for most cirrhotic patients with ascites. 1 Only institute fluid restriction if serum sodium falls below 120-125 mmol/L. 1 Chronic hyponatremia in this population is seldom morbid and attempts at rapid correction can cause more complications than the hyponatremia itself. 1

Monitoring and Follow-up

• If TIPS is successfully placed, discontinue vasoactive drugs and monitor TIPS patency with Doppler ultrasound every 6 months. 1
• Patients not receiving TIPS require ongoing surveillance endoscopy and adherence to beta-blocker therapy to prevent recurrent bleeding. 1