What is the recommended management of an acute upper gastrointestinal (GI) bleed in a patient with chronic liver disease according to the European Association for the Study of the Liver (EASLD) guidelines?

Management of Upper GI Bleed in Chronic Liver Disease According to EASL

In patients with chronic liver disease and suspected upper GI bleeding, immediately initiate vasoactive drug therapy (terlipressin, somatostatin, or octreotide) and antibiotic prophylaxis with ceftriaxone before endoscopy, while implementing restrictive blood transfusion (hemoglobin threshold 7 g/dL, target 7-9 g/dL) and performing endoscopy within 12 hours once hemodynamically stable. 1

Initial Resuscitation (ABC Approach)

Airway, Breathing, Circulation

• Assess and secure airway immediately, particularly in patients with massive bleeding or hepatic encephalopathy who may require endotracheal intubation for airway protection 1
• Volume replacement with crystalloids (or colloids if needed) to restore hemodynamic stability 1
• Insert two large-bore IV cannulae in the anticubital fossae for patients who are hemodynamically compromised 1

Restrictive Transfusion Strategy

• Transfuse red blood cells only when hemoglobin falls below 7 g/dL, targeting 7-9 g/dL 1
• This restrictive approach is critical because blood product administration increases portal pressure, which paradoxically worsens bleeding outcomes 1
• Avoid transfusion at higher hemoglobin thresholds as this has been associated with failure to control bleeding and early rebleeding 1

Immediate Pharmacological Therapy (Before Endoscopy)

Vasoactive Drug Therapy

Start vasoactive drugs immediately upon suspicion of variceal bleeding, even before endoscopic confirmation 1

Choose one of the following regimens:

• Terlipressin: 2 mg IV every 4 hours for first 48 hours, then 1 mg every 4 hours 1
• Somatostatin: 250 µg IV bolus, then continuous infusion of 250 µg/hour (can increase to 500 µg/hour) 1
• Octreotide: 50 µg IV bolus, then continuous infusion of 50 µg/hour 1

Continue vasoactive therapy for 3-5 days after endoscopic confirmation to prevent early rebleeding 1

Antibiotic Prophylaxis

• Ceftriaxone 1 g IV daily is the first-line choice in patients with decompensated cirrhosis, those on quinolone prophylaxis, or in settings with high quinolone resistance 1
• Alternative: Norfloxacin (if ceftriaxone unavailable and no resistance concerns) 1
• Continue for up to 7 days 1
• This reduces infection incidence (which occurs in >50% of patients), improves bleeding control, and enhances survival 1

Endoscopic Management

Timing and Preparation

• Perform upper endoscopy within 12 hours of admission once hemodynamic stability is achieved 1, 2
• Administer erythromycin 250 mg IV 30-120 minutes before endoscopy to improve gastric emptying and visibility, unless contraindicated (QT prolongation) 1, 2

Endoscopic Therapy Based on Findings

For Esophageal Varices:

• Endoscopic band ligation (EBL) is the treatment of choice 1, 2
• EBL is more effective than sclerotherapy with fewer adverse effects and may improve survival 1
• Sclerotherapy can be used only when ligation is technically not feasible 1

For Gastric (Cardiofundal) Varices:

• Cyanoacrylate injection or EBL are both acceptable 1, 2
• EBL should only be performed on small gastric varices where the complete vessel can be suctioned into the ligation device 1

Critical Point: Up to 30% of cirrhotic patients bleed from non-variceal causes, making endoscopy essential for diagnosis 1

Management of Treatment Failure

Rescue Therapy

For persistent bleeding or early rebleeding despite endoscopic and pharmacological therapy:

• Transjugular intrahepatic portosystemic shunt (TIPS) is the rescue therapy of choice 1, 2
• Balloon tamponade can serve as a temporary bridge while awaiting definitive treatment 1

Early Pre-emptive TIPS (High-Risk Patients)

Consider early TIPS within 72 hours (preferably within 24 hours) in:

• Child-Pugh class C patients with score ≤13 2
• Child-Pugh class B patients with score >7 who have active bleeding at endoscopy despite vasoactive agents 2
• Patients with HVPG >20 mmHg 2

This pre-emptive approach significantly improves outcomes in high-risk patients 2

Prevention of Complications

Key Complications to Monitor

• Bacterial infections (present in >50% of patients; may precipitate bleeding) 1
• Hepatic encephalopathy - manage with lactulose or lactitol 1
• Renal function deterioration - avoid nephrotoxic drugs, maintain adequate fluid balance 1
• Aspiration pneumonia 1
• Spontaneous bacterial peritonitis 1

Medications to Avoid During Acute Episode

• Discontinue beta-blockers, diuretics, and other hypotensive medications 1
• Avoid nephrotoxic drugs (NSAIDs, aminoglycosides) 1
• Avoid large volume paracentesis during active bleeding 1

Secondary Prophylaxis (After Bleeding Control)

Once bleeding is controlled, initiate secondary prophylaxis with:

• Non-selective beta-blockers (NSBBs) and/or endoscopic band ligation 2
• Repeat EBL sessions every 1-4 weeks until variceal eradication (typically 2-4 sessions) 2
• Surveillance endoscopy every 3-6 months after eradication to monitor for recurrence 2

Beta-Blocker Cautions

• Use with caution in patients with severe or refractory ascites 2
• Discontinue if systolic blood pressure falls below 90 mmHg 2
• Avoid during acute intercurrent conditions 2

Common Pitfalls to Avoid

1. Delaying vasoactive therapy until endoscopy - these drugs must be started immediately upon suspicion 1
2. Liberal transfusion strategy - overtransfusion increases portal pressure and worsens outcomes 1
3. Omitting antibiotic prophylaxis - infections are independent predictors of failure to control bleeding and death 1
4. Performing endoscopy before hemodynamic stabilization - resuscitation must be achieved first 1
5. Continuing beta-blockers during acute bleeding - these should be held during the acute episode 1
6. Using tranexamic acid - this has shown no benefit in variceal bleeding and may increase venous thromboembolic events 1
7. Routine use of FFP, platelets, or recombinant factor VIIa - these are not recommended as they do not improve outcomes and may worsen portal hypertension 1