Management of GI Bleeding in Cirrhosis

Initial Resuscitation and Stabilization

The American Association for the Study of Liver Diseases recommends assessing airway, breathing, and circulation immediately, with prompt volume replacement using crystalloids to restore and maintain hemodynamic stability 1, 3
A restrictive transfusion strategy with a hemoglobin threshold of 7 g/dL and target range of 7-9 g/dL is recommended to avoid increasing portal pressure and risk of rebleeding 2, 3, 4
Placement of at least two large-bore intravenous catheters is recommended to facilitate rapid volume expansion 1
Airway protection with endotracheal intubation should be considered in patients with massive bleeding or hepatic encephalopathy 5
Nephrotoxic drugs, large volume paracentesis, beta-blockers, and other hypotensive medications should be avoided during the acute bleeding episode 3

Vasoactive drug therapy should be started immediately upon suspicion of variceal bleeding, even before endoscopic confirmation 2, 3
The choice of vasoactive agent includes terlipressin, somatostatin, or octreotide, which should be continued for 3-5 days after endoscopic therapy 2, 3, 6
Antibiotic prophylaxis should be initiated immediately and continued for up to 7 days to reduce infection risk, improve bleeding control, and enhance survival 3, 4
Ceftriaxone 1 g IV daily is the first choice in patients with decompensated cirrhosis, those on quinolone prophylaxis, or in settings with high quinolone resistance 7

Upper endoscopy should be performed within 12 hours of admission once hemodynamic stability is achieved 3, 6
Pre-endoscopy erythromycin (250 mg IV, 30-120 minutes before) can be used to improve visibility if no contraindications exist 2, 3
Endoscopic band ligation (EBL) is the preferred endoscopic therapy for esophageal varices 2, 3
Cyanoacrylate injection or EBL can be used for gastric varices 6, 8

Transjugular intrahepatic portosystemic shunt (TIPS) is the rescue therapy of choice for persistent bleeding or early rebleeding 3, 7
Balloon tamponade can be used as a temporary bridge in cases of uncontrolled bleeding while awaiting definitive treatment 7, 8
Early pre-emptive covered TIPS can be considered in high-risk patients, such as Child-Pugh class C with score <14 or selected Child-Pugh class B patients with active bleeding 3, 7

Hepatic encephalopathy should be monitored for and managed with lactulose or lactitol when it develops 3, 9
Adequate fluid and electrolyte balance should be maintained to preserve renal function 3
Short-course proton pump inhibitor therapy can be considered after endoscopic band ligation to reduce post-banding ulcer size 3

Secondary prophylaxis should be initiated with non-selective beta-blockers (NSBBs) and/or endoscopic band ligation once bleeding is controlled 1, 10
NSBBs should be used with caution in patients with severe or refractory ascites, and high doses should be avoided 1, 10
NSBBs should be discontinued if systolic blood pressure falls below 90 mmHg or during acute intercurrent conditions 1, 10

Repeat endoscopic band ligation sessions should be scheduled at 7-14 day intervals until variceal obliteration, typically requiring 2-4 sessions 8
After eradication, surveillance endoscopy should be performed every 3-6 months to evaluate for variceal recurrence 8