Management of Upper Gastrointestinal Bleeding in Chronic Liver Disease

Initial Assessment and Resuscitation

The American Association for the Study of Liver Diseases recommends immediate resuscitation with crystalloids and restrictive blood transfusion (hemoglobin threshold of 7 g/dL) in patients with chronic liver disease and upper GI bleeding 1
Patients with chronic liver disease and upper GI bleeding should have airway, breathing, and circulation assessed immediately, with prompt volume replacement using crystalloids to restore hemodynamic stability 1
A restrictive transfusion strategy (hemoglobin threshold of 7 g/dL, target 7-9 g/dL) should be implemented to avoid increasing portal pressure and risk of rebleeding in patients with chronic liver disease and upper GI bleeding 1
Shock, indicated by a pulse greater than 100 beats per minute or systolic blood pressure less than 100 mmHg, suggests severe bleeding in patients with chronic liver disease 2

Vasoactive drug therapy, such as terlipressin, somatostatin, or octreotide, should be started immediately upon suspicion of variceal bleeding in patients with chronic liver disease, even before endoscopic confirmation, to reduce splanchnic blood flow and portal pressure 1, 3
Antibiotic prophylaxis should be initiated immediately in patients with chronic liver disease and upper GI bleeding and continued for up to 7 days, with ceftriaxone 1g IV daily preferred in decompensated cirrhosis 1

The severity of liver disease is a key prognostic factor in patients with chronic liver disease and upper GI bleeding, with the Rockall scoring system used to assess risk of rebleeding and death 2
Patients with liver failure receive 3 points in the comorbidity section of the Rockall score, indicating a higher risk of poor outcomes 2

Upper endoscopy should be performed within 12 hours of admission in patients with chronic liver disease and upper GI bleeding, once hemodynamic stability is achieved 1
Endoscopic band ligation is the preferred treatment for esophageal varices in patients with chronic liver disease and upper GI bleeding 1

Transjugular intrahepatic portosystemic shunt (TIPS) should be used as rescue therapy for persistent bleeding or early rebleeding in patients with chronic liver disease and upper GI bleeding 1
Balloon tamponade can be used as a temporary bridge in cases of uncontrolled bleeding while awaiting definitive treatment in patients with chronic liver disease and upper GI bleeding 1, 3

Hepatic encephalopathy should be monitored for and managed with lactulose or lactitol in patients with chronic liver disease and upper GI bleeding 1
Comorbid conditions that may be decompensated by bleeding should be treated in patients with chronic liver disease and upper GI bleeding 2

Secondary prophylaxis with non-selective beta-blockers (NSBBs) and/or endoscopic band ligation should be initiated once bleeding is controlled in patients with chronic liver disease and upper GI bleeding 1
NSBBs should be used with caution in patients with severe or refractory ascites, and discontinued if systolic blood pressure falls below 90 mmHg 1