• 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).

• 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

• Endoscopy early – ideally within 12-24 hours
• Be familiar with a Blakemore tube
• Blackemore tube placement video
• Blackemore tube placement clinical summary

Almost all will be admitted.

Local ability to monitor and resuscitate and treat.

No discharge criteria currently available as most are admitted.

1. Kalafateli M, Triantos CK, Nikolopoulou VA, Burroughs A. Non-variceal gastrointestinal bleeding in patients with liver cirrhosis: a review. Digestive diseases and sciences. 2012 Nov 1;57(11):2743-54.

   
   

2. Cremers I, Ribeiro S. Management of variceal and nonvariceal upper gastrointestinal bleeding in patients with cirrhosis. Therapeutic Advances in Gastroenterology. 2014 Sep;7(5):206-16.

   
   

3. 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.