Upper Gastrointestinal Bleeds in Patients with Cirrhosis
Cardinal Presentations / Presenting Problems, Gastrointestinal
- GI bleeding accounts for up to 25% of overall mortality in patients with cirrhosis.
- Patients with cirrhosis of the liver may present with gastrointestinal bleeding either related to:
- portal hypertension, most commonly gastroesophageal varices and portal gastropathy and
- lesions seen in the general population: peptic ulcer, erosive gastritis, reflux esophagitis, Mallory–Weiss syndrome, tumours, etc.
- The most frequent causes of acute bleeding in the cirrhotic patient are:
- esophageal varices (60-70%),
- peptic gastric and duodenal ulcers (20-25%),
- portal hypertension gastropathy (9.5%),
- gastric varices (5.1%).
- The mortality in all bleeding cirrhotic patients is approximately 10-20%, but up to 40% in patients with severe liver dysfunction (Child-Pugh B or C disease).
- The standard of care of Upper Gastrointestinal Bleeds (UGIB) in patients with cirrhosis includes:
- Careful resuscitation, preferably in an ICU setting, medical and endoscopic therapy, early consideration for placement of transjugular intrahepatic portosystemic shunt (TIPS) and, sometimes, surgical therapy or hepatic transplant.
- Both under and over resuscitation should be avoided.
- Normal INR = helpful; but difficult to interpret what an abnormal INR tells us in terms of bleeding risk in cirrhosis.
- Try to avoid plasma if possible (over transfusion with fresh frozen plasma and platelets causes an increase in portal pressure and may lead to continued bleeding and re-bleeding).
- Transfuse for Hgb < 70; platelets < 50
- Follow fibrinogen; treat with cryoprecipitate or concentrate if < 3.0 μmol/L
- Vasopressin no longer used due to many side effects
- Antibiotics (ceftriaxone, quinolones) are helpful
- Octreotide is probably helpful (50 microgram bolus; 50 mcg/hr.)
- PPI’s probably not helpful
- Value of tranexamic acid unclear.
Criteria For Hospital Admission
Almost all will be admitted.
Criteria For Transfer To Another Facility
Local ability to monitor and resuscitate and treat.
Criteria For Safe Discharge Home
No discharge criteria currently available as most are admitted.
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Tripathi D, Stanley AJ, Hayes PC, Patch D, Millson C, Mehrzad H, Austin A, Ferguson JW, Olliff SP, Hudson M, Christie JM. UK guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut. 2015 Nov 1;64(11):1680-704.
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Mar 25, 2019
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