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    Upper Gastrointestinal Bleeds in Patients with Cirrhosis

    Cardinal Presentations / Presenting Problems, Gastrointestinal

    Last Updated Mar 25, 2019
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    Context

    • 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:
    1. portal hypertension, most commonly gastroesophageal varices and portal gastropathy and
    2. 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:
    1. esophageal varices (60-70%),
    2. peptic gastric and duodenal ulcers (20-25%),
    3. portal hypertension gastropathy (9.5%),
    4. 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).

    Recommended Treatment

    • 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

    Medications

    • 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.

    Definitive Therapy

    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?

    Justification

    Moderate

    Related Information

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