Management of variceal and nonvariceal upper gastrointestinal bleeding in patients with cirrhosis

Abstract

Acute upper gastrointestinal haemorrhage remains the most common medical emergency managed by gastroenterologists. Causes of upper gastrointestinal bleeding (UGIB) in patients with liver cirrhosis can be grouped into two categories: the first includes lesions that arise by virtue of portal hypertension, namely gastroesophageal varices and portal hypertensive gastropathy; and the second includes lesions seen in the general population (peptic ulcer, erosive gastritis, reflux esophagitis, Mallory-Weiss syndrome, tumors, etc.). Emergency upper gastrointestinal endoscopy is the standard procedure recommended for both diagnosis and treatment of UGIB. The endoscopic treatment of choice for esophageal variceal bleeding is band ligation of varices. Bleeding from gastric varices is treated by injection with cyanoacrylate. Treatment with vasoactive drugs as well as antibiotic treatment is started before or at the same time as endoscopy. Bleeding from portal hypertensive gastropathy is less frequent, usually chronic and treatment options include β-blocker therapy, injection therapy and interventional radiology. The standard of care of UGIB in patients with cirrhosis includes careful resuscitation, preferably in an intensive care setting, medical and endoscopic therapy, early consideration for placement of transjugular intrahepatic portosystemic shunt and, sometimes, surgical therapy or hepatic transplant.

Portal hypertensive gastropathy: A systematic review of the pathophysiology, clinical presentation, natural history and therapy

“…Propranolol can be used for primary prophylaxis for severe PHG, and can significantly reduce the risk of bleeding. However, scant evidence exists that this reduction will affect the risk of a primary bleeding episode in PHG patients [72,103,104,269,270] . Propranolol is recommended regardless of the severity or presence of PHG in patients with esophageal varices because it treats both entities by reducing portal pressure [105][106][107]198,271,272] .…”

“…Primary prophylaxis is, therefore, not recommended for patients with mild PHG [72,191,269] . Propranolol can be used for primary prophylaxis for severe PHG, and can significantly reduce the risk of bleeding.…”

Prognostic performance of clinical indices and model scorings for acute-on-chronic liver failure: A study of 164 patients

“…Upper gastrointestinal hemorrhage is a critical complication associated with ACLF; it is predominantly associated with high intravascular pressure, blood coagulation dysfunction and esophageal gastric varices, which exist prior to the occurrence of the bleeding (21). Through blood volume reduction, organ ischemia and hypoxia, multiple organ function failure may occur (22).…”

Bacteremia in cirrhotic patients with upper gastrointestinal bleeding

“…In patients with cirrhosis, upper gastrointestinal bleeding (UGIB) is a common complication resulting in critical morbidity and mortality (1)(2)(3). Variceal bleeding accounts for >50% cirrhotic patients with UGIB compared to peptic ulcer bleeding, which accounts for only approximately 20% (4).…”