Upper GI Bleed in Cirrhosis

Gastroesophageal Varices and Hemorrhage – Patricia Checinski

Background

  • Form due to portosystemic collaterals and enlarge in the setting of portal HTN, typically through the coronary and/or short gastric veins
  • Mechanistically: intrahepatic resistance to portal flow from regenerative nodules and fibrosis, as well as # intrahepatic vascular tone due to endothelial dysfunction
  • Variceal hemorrhage is the cause of ~ 70% of UGIB in pts with portal HTN
  • The risk of mortality with each episode of esophageal variceal hemorrhage (EVH) is 15-25%. Recurrence occurs in 60% of patients within 1-2 years of the index event

 

Variceal Screening:

  • Not all pts with cirrhosis require screening. Can be omitted with low liver stiffness (on elastography) and with platelets >150; otherwise screening is necessary.
  • Compensated cirrhosis w/o varices EGD q3yr, unless active liver injury (obesity, EtOH use, ongoing viral infxn), then q2yr
  • Compensated cirrhosis w/small varices EGD q2yr unless active liver injury, then q1yr
  • Decompensated cirrhosis with no or small nonbleeding varices EGD q1yr, and at initial time of decompensation
  • If these pts are on Non-selective β-blocker (NSBB) for 1º ppx w/HR 55-60, no need to screen

 

Management (Non-Bleeding Varices)

  • Indicated for medium to large varices or high-risk small varices (with red signs)
  • Primary ppx with either NSBB (preferred) or endoscopic band ligation (EBL), not both
  • NSBB: decrease hepatic venous pressure gradient (HVPG) and portal venous flow by decreasing cardiac output (β1 blockade) and allowing unopposed alpha-adrenergic activity (β2 blockade). Start NSBB such as nadolol (given nightly as portal pressures are highest at night) or propranolol (BID). Carvedilol has been shown to have a greater reduction in portal pressures and may be most preferred if tolerated.
      • For 2 º ppx, initiate ~72hr after acute bleed has resolved and octreotide discontinued
      • Titrate dose to reduce resting HR by ~25% (or target HR 55-60)
      • Ask pt to check their HR and BP 2-3 days after discharge or after clinic visit and contact provider for further titration
      • Discontinue if: hypotension, AKI, SBP or hyponatremia (w/refractory ascites)
  • EBL is performed in medium to large varices, any varices with red wale marks
  • For secondary ppx, pts should be on BB AND undergo EBL. BB are associated with reduced mortality, while EBL is not (EBL does not eradicate the HVPG)
  • TIPS should not be used for primary ppx

 

Management (Variceal Bleeding)

  • Assess severity: tachycardia suggests 10% volume loss, orthostatic hypotension 20% volume loss, shock 30% volume loss
  • Place two large-bore IVs (18G or larger), resuscitate w/ blood products and albumin
  • If hypotensive, try MAC placement and activate massive transfusion protocol (MTP)
  • Consider intubation if need for emergent EGD, change in mental status, ongoing hematemesis, concern of ability to protect airway
  • Start octreotide 50 mcg IV bolus followed by continuous infusion of 50 mcg/h, to be continued for 3 days should EVH be confirmed on endoscopy
  • Ceftriaxone 1g IV q24h for SBP prophylaxis (reduced mortality), then transition to PO ciprofloxacin for total 7-day course
  • IV protonix 40 mg BID (can dc after EGD if no ulcer)
  • Consult GI or alert fellow for upper endoscopy. Endoscopic therapies performed include variceal band ligation and sclerotherapy. EBL is more effective than sclerotherapy to control bleeding, sclerotherapy is used when ligation is not feasible. Repeat endoscopy if re-bleeding occurs after initial successful therapy.
  • Consider balloon tamponade with Blakemore as temporizing measure before definitive management. Patient must be intubated before placement, and preferably GI should be made aware prior to placement.
  • No role for the correction of INR, even in the presence of bleeding as excessive blood products and FFP can increase portal pressures and cause worsening bleeding
    • Vitamin K can be given w/  INR, though is unlikely to help in the acute setting
    • Check Fibrinogen and give cryo if fibrinogen is <120 given its low volume
    • AASLD does not recommend specific platelet targets during variceal hemorrhage
    • Administer blood products in balanced ratio to avoid transfusion related coagulopathy (VUMC MTP is 6:4:1 of RBC:FFP:PLT)
  • Transjugular intrahepatic portosystemic shunt (TIPS) can be considered as a rescue therapy for rebleeding or refractory bleeding, or occasionally as preemptive therapy,
    • Order TTE early in course, as well as triple phase CT for pre-procedural planning. Duplex of portal and hepatic veins can be substituted in the setting of severe AKI
    • TIPS is relatively contraindicated in pts with elevated MELD, evidence of R heart dysfunction, and active or difficult to control hepatic encephalopathy
    • TIPS can be considered “preemptively” if bleeding was controlled in pts at high risk of failure or rebleeding (Child B 8-9 with active bleeding on prior endoscopy or Child C 10-13 regardless of endoscopy findings)
    • For gastric varices, endoscopic management can be attempted with EBL or sclerotherapy. TIPS should be considered early in pts with cardiofundal varices, though other interventional options are coiling via IR with BATO and BRT
      • Recent data supports BRTO over glue injection for gastric varices
  • Following TIPS placement, there is no need for NSBB or EVL, as the TIPS has decompressed the portal system and should be considered definitive management.
    • Recurrent bleeding should prompt investigation of the TIPS