GI Bleeding in Patient with Known Cirrhosis

• Differential diagnosis:
  • Variceal (50-90% of bleeds in pts with cirrhosis)
    • Epidemiology:
      • 50% stop spontaneously (vs 90% of all other UGIB)
      • High rate of re-bleed within 6 weeks
      • Two-year survival of 40% after first bleed
    • Pathophysiology:
      • Ohm's law: Portal pressure = portal flow x outflow resistance
        • Portal HTN results from increased flow from splanchnic vasodilatation and increased resistance from distorted hepatic sinusoids
      • Varices form to relieve portal HTN and shunt portal drainage into systemic circulation
        • Occur when hepatic venous pressure gradient (portal pressure - hepatic vein pressure) is greater than 10mm Hg
  • Portal hypertensive gastropathy (snakeskin stomach)
    • Results form increased gastric mucosal blood flow, and presents as oozing
    • Treatment involves decreasing portal pressure: propranolol, TIPS, portocaval shunt, transplantation
  • Gastric antral vascular ectasia (watermelon stomach)
    • Ectatic mucosal vessels, presents as episodic bleeding
    • Treat with endoscopic coagulation (e.g. Argon)
  • Peptic ulcer disease/gastritis/esophagitis
  • Mallory-Weiss tear

• Management:
  • As in all UGIB, initial step is stabilization and evaluation of ABCs
    • NG lavage should be performed to confirm diagnosis and determine if high risk bleed is present (i.e. fresh blood)
      • However, can yield false negative if pylorus is closed - presence of bilious aspirate indicates that duodenum has been interrogated
    • Stool should be examined, but is not a reliable discriminator between upper and lower sources, as rapid UGIB can result in hematochezia
  • Medical therapy:
    • Octreotide: inhibits vasodilatory hormones such as glucagon, resulting in splanchnic vasoconstriction and decreased portal flow
      • Effective in controlling bleeding, but no mortality benefit
    • Acid suppression: promotes clot formation
      • Only studied in PUD, but should be used given that cause of bleed unclear until EGD, and same hemostatic principles apply
    • Antibiotics: bacterial superinfection present in 20% of UGIB in cirrhotics, probably from translocation
      • Optimal antibiotic unknown, but should cover GNRs (3rd gen cephalosporin, fluoroquinolone)
    • Should treat for short course (e.g. 7d) barring identification of another infection (e.g. pneumonia, bacteremia)
  • Endoscopic therapy:
    • Sclerotherapy
    • Band ligation: shown to be superior to sclerotherapy (see attached NEJM article)
  • Rescue therapy:
    • Balloon tamponade
    • Surgery (shunt, transection, devascularization)
    • TIPS
  • Prophylaxis
    • Beta blockers: attenuate vasodilatory tone of mesenteric arterioles, thus decreasing portal flow
    • Nitrates: may increase mortality, so should not be used routinely

(Christopher Woo MD, 9/10/10)