From the Guidelines
The most common cause of upper gastrointestinal bleeding in patients with cirrhosis is variceal hemorrhage, accounting for approximately 70% of all upper gastrointestinal hemorrhage in these patients. This is due to the development of portal hypertension, a hallmark feature of cirrhosis, which causes blood to seek alternate pathways through collateral vessels, including those in the esophagus and stomach, leading to the formation of esophageal and gastric varices [ 1 ]. These varices are prone to rupture and bleeding, resulting in significant morbidity and mortality.
Key Points
- Variceal hemorrhage is a major complication of cirrhosis, with an in-hospital mortality rate of 4%–13% and a 6-week mortality rate of 7%–43% [ 1 ].
- Vasoactive drugs, such as octreotide or terlipressin, should be initiated as soon as variceal hemorrhage is suspected or confirmed, and continued for 2–5 days to prevent early rebleeding [ 1 ].
- Endoscopic therapy, including band ligation for esophageal varices or cyanoacrylate injection for gastric varices, is also essential in the management of variceal hemorrhage [ 1 ].
- The combination of endoscopic therapy and vasoactive drugs is more effective than the isolated use of either of these options alone, and is currently considered the standard of care in variceal hemorrhage [ 1 ].
Management
- Immediate hemodynamic stabilization and blood product transfusion as needed are crucial in the management of variceal hemorrhage.
- Antibiotic prophylaxis is recommended to reduce the incidence of infections and improve control of bleeding and survival [ 1 ].
- Renal function should be preserved by adequate replacement of fluids and electrolytes, and nephrotoxic drugs should be avoided [ 1 ].
From the Research
Causes of Upper Gastrointestinal Bleeding in Patients with Cirrhosis
- The most common cause of upper gastrointestinal bleeding in patients with cirrhosis is esophageal varices, as reported in a study published in 2.
- Approximately 40% to 95% of people with liver cirrhosis have oesophageal varices, and about 15% to 20% of oesophageal varices bleed within one to three years after diagnosis, according to a study published in 3.
- Alcoholic cirrhosis is the main cause of portal hypertension, which leads to esophageal varices, as stated in 2.
Prevalence of Variceal Bleeding
- Varices remain the most common cause of upper gastrointestinal bleeding in both males and females, with a higher percentage in males, as reported in 2.
- A study published in 2 found that 42.5% of patients with upper gastrointestinal bleeding had varices.
- Variceal bleeding is an important cause of massive upper gastrointestinal bleeding, accounting for 66.7% of cases, as stated in 2.
Comparison with Other Causes
- Non-variceal sources of upper gastrointestinal bleeding, such as peptic ulcer disease and erosive gastritis, are also common, but variceal bleeding is more prevalent in patients with cirrhosis, as reported in 2 and 4.
- A study published in 4 found that non-variceal sources accounted for 80.1% of upper gastrointestinal bleeding cases, but this study did not specifically focus on patients with cirrhosis.