Management of bleeding in the cirrhotic patient

Abstract

Important advances have been made in the management of variceal bleeding. Despite these advances, bleeding in the patient with cirrhosis remains one of the most demanding clinical challenges that a gastroenterologist or gastrointestinal surgeon may face. The aim is to identify the source of bleeding, control active bleeding and prevent rebleeding. This requires a multidisciplinary team, and the optimal management algorithm depends on the clinical circumstance of the patient and the local availability of endoscopic, radiological and surgical expertise. Injection sclerotherapy is effective in stopping acute variceal bleeding, but has the drawback of a high incidence of complications. Endoscopic variceal ligation is just as effective, and is associated with fewer complications. An overtube allows repeated introductions of the endoscope to be more tolerable for the patient and protects the airway against aspiration of blood; its use should be encouraged in patients with massive bleeding. Newer ligators can deliver multiple bands without removal of the scope but the high cost of these disposable devices limits their widespread use. Bleeding from gastric varices is even more challenging; the treatment of choice is injection with cyanoacrylate glue. To prevent rebleeding, beta-blockers are recommended for all patients with large varices (including those which have never bled). Injection sclerotherapy or band ligation, conducted at weekly intervals after the initial control of bleeding, is equally effective at obliterating varices and decreasing the risk of further hemorrhage; band ligation results in fewer complications. Other newer treatment modalities for variceal bleeding, such as somatostatin analogs, transjugular intrahepatic portasystemic shunt and liver transplantation, offer more optimal approaches to control bleeding and prevent rebleeding, but may be prohibitively expensive. Even for the most affluent communities, affordability, cost-effectiveness, and resource rationing are important considerations in management of patients with cirrhosis complicated by gastrointestinal bleeding.

Changing Trends in the Epidemiology and Clinical Outcome of Acute Upper Gastrointestinal Bleeding in a Defined Geographical Area in Greece

“…13 The wide variation in bleeding mortality rates from 3% to 15% may partly be explained either by case selection or by the fact that many of these studies are undertaken in specialized centers. [1][2][3][4][5][6][7][8][9][10][11][12][13]15,28 In our study we included all patients presenting with AUGIB in our area, both in university and nonuniversity hospitals. Almost half of our patients have none or mild coexisting diseases.…”

“…[1][2][3][4][5] During the past years major advances in the diagnostic and therapeutic approaches have been achieved, mainly in peptic ulcer disease, cirrhosis, and portal hypertension. [6][7][8] The available guidelines for the management of peptic ulcers and prevention of bleeding in patients with portal hypertension are thought to offer better handling of these common diseases. 9,10 Eradication of Helicobacter pylori, the offending agent for ulcer formation, has changed the natural history of peptic ulcer disease and has led to a reduction in ulcer recurrences and complications, especially bleeding.…”

Chronic constipation: diagnosis and current treatment options

“…Indeed, in healthy volunteers drinking 2 litres of hypotonic or isotonic fluid daily there was no reported increase in stool output. 13 Furthermore, in a study of 883 individuals aged over 70 years fluid intake did not show any correlation with chronic constipation. 14 It also remains unclear whether or not fluid is required to increase the efficacy of fibre in chronic constipation.…”

Role of Emergency Transjugular Intrahepatic Portosystemic Shunts

“…2 The high mortality of these patients is due to a combination of massive bleeding due to the elevated portal pressure, compromised hepatic reserve, and multiorgan failure. 3 Patients with massive hemorrhage from esophageal varices represent a considerable challenge to clinicians. No single therapy is appropriate for all patients with bleeding varices.…”