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Management of Upper GI Bleeding in Cirrhotic Patients

  • Alexander DechêneEmail author
Chapter

Abstract

Portal hypertension in patients with liver cirrhosis is the main factor contributing to the formation of esophageal or gastric varices. The risk of bleeding reflects the grade of portal hypertension and can be estimated using invasive or noninvasive methods. Primary prevention of variceal bleeding can be achieved using pharmacologic or endoscopic interventions.

Given that upper gastrointestinal hemorrhage from varices is associated with significant mortality, the major aims of acute management are hemodynamic stabilization, pharmacologic reduction of portal pressure, and endoscopic treatment of bleeding vessels, as well as prevention and treatment of concomitant infections. In patients with treatment failure, rescue options include implantation of esophageal stents and placement of transjugular intrahepatic portosystemic shunts (TIPS).

After hemostasis is achieved, the risk of rebleeding should be evaluated, as certain groups of patients benefit from early placement of TIPS whereas others can safely be managed with a combination of pharmacologic and endoscopic modalities.

Acute hemorrhage from portal hypertensive gastropathy is significantly less frequent than variceal hemorrhage and can be managed noninvasively in most patients.

Keywords

Gastrointestinal bleeding Gastroesophageal varices Portal hypertensive gastropathy Portal hypertension Variceal band ligation Transjugular intrahepatic portosystemic shunt Primary prevention Secondary prevention 

References

  1. 1.
    Ripoll C, Groszmann R, Garcia-Tsao G, Grace N, Burroughs A, Planas R, et al. Hepatic venous pressure gradient predicts clinical decompensation in patients with compensated cirrhosis. Gastroenterology. 2007;133:481–8.CrossRefGoogle Scholar
  2. 2.
    Rockey DC, Elliott A, Lyles T. Prediction of esophageal varices and variceal hemorrhage in patients with acute upper gastrointestinal bleeding. J Investig Med. 2016;64:745–51.CrossRefGoogle Scholar
  3. 3.
    D’Amico G, Pasta L, Morabito A, D’Amico M, Caltagirone M, Malizia G, et al. Competing risks and prognostic stages of cirrhosis: a 25-year inception cohort study of 494 patients. Aliment Pharmacol Ther. 2014;39:1180–93.CrossRefGoogle Scholar
  4. 4.
    Fontana RJ, Sanyal AJ, Mehta S, Doherty MC, Neuschwander-Tetri BA, Everson GT, et al. Portal hypertensive gastropathy in chronic hepatitis C patients with bridging fibrosis and compensated cirrhosis: results from the HALT-C trial. Am J Gastroenterol. 2006;101:983–92.CrossRefGoogle Scholar
  5. 5.
    Llop E, Lopez M, de la Revilla J, Fernandez N, Trapero M, Hernandez M, et al. Validation of noninvasive methods to predict the presence of gastroesophageal varices in a cohort of patients with compensated advanced chronic liver disease. J Gastroenterol Hepatol. 2017;32:1867–72.CrossRefGoogle Scholar
  6. 6.
    Berzigotti A, Seijo S, Arena U, Abraldes JG, Vizzutti F, Garcia-Pagan JC, et al. Elastography, spleen size, and platelet count identify portal hypertension in patients with compensated cirrhosis. Gastroenterology. 2013;144:102–11.e1.CrossRefGoogle Scholar
  7. 7.
    Kovalak M, Lake J, Mattek N, Eisen G, Lieberman D, Zaman A. Endoscopic screening for varices in cirrhotic patients: data from a national endoscopic database. Gastrointest Endosc. 2007;65:82–8.CrossRefGoogle Scholar
  8. 8.
    Groszmann RJ, Garcia-Tsao G, Bosch J, Grace ND, Burroughs AK, Planas R, et al. Beta-blockers to prevent gastroesophageal varices in patients with cirrhosis. N Engl J Med. 2005;353:2254–61.CrossRefGoogle Scholar
  9. 9.
    Abraldes JG, Bureau C, Stefanescu H, Augustin S, Ney M, Blasco H, et al. Noninvasive tools and risk of clinically significant portal hypertension and varices in compensated cirrhosis: the “anticipate” study. Hepatology. 2016;64:2173–84.CrossRefGoogle Scholar
  10. 10.
    Maurice JB, Brodkin E, Arnold F, Navaratnam A, Paine H, Khawar S, et al. Validation of the Baveno VI criteria to identify low risk cirrhotic patients not requiring endoscopic surveillance for varices. J Hepatol. 2016;65:899–905.CrossRefGoogle Scholar
  11. 11.
    Carbonell N, Pauwels A, Serfaty L, Fourdan O, Levy VG, Poupon R. Improved survival after variceal bleeding in patients with cirrhosis over the past two decades. Hepatology. 2004;40:652–9.CrossRefGoogle Scholar
  12. 12.
    de Franchis R, Baveno VIF. Expanding consensus in portal hypertension: report of the Baveno VI consensus workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol. 2015;63:743–52.CrossRefGoogle Scholar
  13. 13.
    Tripathi D, Stanley AJ, Hayes PC, Patch D, Millson C, Mehrzad H, et al. U.K. guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut. 2015;64:1680–704.CrossRefGoogle Scholar
  14. 14.
    Qi XS, Bao YX, Bai M, Xu WD, Dai JN, Guo XZ. Nonselective beta-blockers in cirrhotic patients with no or small varices: a meta-analysis. World J Gastroenterol. 2015;21:3100–8.CrossRefGoogle Scholar
  15. 15.
    Cheng JW, Zhu L, Gu MJ, Song ZM. Meta analysis of propranolol effects on gastrointestinal hemorrhage in cirrhotic patients. World J Gastroenterol. 2003;9:1836–9.CrossRefGoogle Scholar
  16. 16.
    Reiberger T, Ulbrich G, Ferlitsch A, Payer BA, Schwabl P, Pinter M, et al. Carvedilol for primary prophylaxis of variceal bleeding in cirrhotic patients with haemodynamic non-response to propranolol. Gut. 2013;62:1634–41.CrossRefGoogle Scholar
  17. 17.
    Gluud LL, Krag A. Banding ligation versus beta-blockers for primary prevention in oesophageal varices in adults. Cochrane Database Syst Rev. 2012;(8):CD004544.Google Scholar
  18. 18.
    Takuma Y, Nouso K, Morimoto Y, Tomokuni J, Sahara A, Takabatake H, et al. Prediction of oesophageal variceal bleeding by measuring spleen stiffness in patients with liver cirrhosis. Gut. 2016;65:354–5.CrossRefGoogle Scholar
  19. 19.
    Gralnek IM, Dumonceau JM, Kuipers EJ, Lanas A, Sanders DS, Kurien M, et al. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2015;47:a1–46.CrossRefGoogle Scholar
  20. 20.
    Gattas DJ, Dan A, Myburgh J, Billot L, Lo S, Finfer S, et al. Fluid resuscitation with 6% hydroxyethyl starch (130/0.4 and 130/0.42) in acutely ill patients: systematic review of effects on mortality and treatment with renal replacement therapy. Intensive Care Med. 2013;39:558–68.CrossRefGoogle Scholar
  21. 21.
    Annane D, Siami S, Jaber S, Martin C, Elatrous S, Declere AD, et al. Effects of fluid resuscitation with colloids vs crystalloids on mortality in critically ill patients presenting with hypovolemic shock: the CRISTAL randomized trial. JAMA. 2013;310:1809–17.CrossRefGoogle Scholar
  22. 22.
    Villanueva C, Colomo A, Bosch A, Concepcion M, Hernandez-Gea V, Aracil C, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013;368:11–21.CrossRefGoogle Scholar
  23. 23.
    D’Amico G, Pagliaro L, Bosch J. The treatment of portal hypertension: a meta-analytic review. Hepatology. 1995;22:332–54.PubMedGoogle Scholar
  24. 24.
    Ioannou G, Doust J, Rockey DC. Terlipressin for acute esophageal variceal hemorrhage. Cochrane Database Syst Rev. 2003;(1):CD002147.Google Scholar
  25. 25.
    Seo YS, Park SY, Kim MY, Kim JH, Park JY, Yim HJ, et al. Lack of difference among terlipressin, somatostatin, and octreotide in the control of acute gastroesophageal variceal hemorrhage. Hepatology. 2014;60:954–63.CrossRefGoogle Scholar
  26. 26.
    Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila F, Soares-Weiser K, Mendez-Sanchez N, Gluud C, et al. Meta-analysis: antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding – an updated Cochrane review. Aliment Pharmacol Ther. 2011;34:509–18.CrossRefGoogle Scholar
  27. 27.
    Theivanayagam S, Lim RG, Cobell WJ, Gowda JT, Matteson ML, Choudhary A, et al. Administration of erythromycin before endoscopy in upper gastrointestinal bleeding: a meta-analysis of randomized controlled trials. Saudi J Gastroenterol. 2013;19:205–10.CrossRefGoogle Scholar
  28. 28.
    Barkun AN, Bardou M, Kuipers EJ, Sung J, Hunt RH, Martel M, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010;152:101–13.CrossRefGoogle Scholar
  29. 29.
    Min YW, Lim KS, Min BH, Gwak GY, Paik YH, Choi MS, et al. Proton pump inhibitor use significantly increases the risk of spontaneous bacterial peritonitis in 1965 patients with cirrhosis and ascites: a propensity score matched cohort study. Aliment Pharmacol Ther. 2014;40:695–704.CrossRefGoogle Scholar
  30. 30.
    Hayat U, Lee PJ, Ullah H, Sarvepalli S, Lopez R, Vargo JJ. Association of prophylactic endotracheal intubation in critically ill patients with upper GI bleeding and cardiopulmonary unplanned events. Gastrointest Endosc. 2017;86:500–9.e1.CrossRefGoogle Scholar
  31. 31.
    Banares R, Albillos A, Rincon D, Alonso S, Gonzalez M, Ruiz-del-Arbol L, et al. Endoscopic treatment versus endoscopic plus pharmacologic treatment for acute variceal bleeding: a meta-analysis. Hepatology. 2002;35:609–15.CrossRefGoogle Scholar
  32. 32.
    Laine L, Cook D. Endoscopic ligation compared with sclerotherapy for treatment of esophageal variceal bleeding. A meta-analysis. Ann Intern Med. 1995;123:280–7.CrossRefGoogle Scholar
  33. 33.
    Kang EJ, Jeong SW, Jang JY, Cho JY, Lee SH, Kim HG, et al. Long-term result of endoscopic Histoacryl (N-butyl-2-cyanoacrylate) injection for treatment of gastric varices. World J Gastroenterol. 2011;17:1494–500.CrossRefGoogle Scholar
  34. 34.
    Ljubicic N, Biscanin A, Nikolic M, Supanc V, Hrabar D, Pavic T, et al. A randomized-controlled trial of endoscopic treatment of acute esophageal variceal hemorrhage: N-butyl-2-cyanoacrylate injection vs. variceal ligation. Hepato-Gastroenterology. 2011;58:438–43.PubMedGoogle Scholar
  35. 35.
    Ibrahim M, El-Mikkawy A, Abdalla H, Mostafa I, Deviere J. Management of acute variceal bleeding using hemostatic powder. United European Gastroenterol J. 2015;3:277–83.CrossRefGoogle Scholar
  36. 36.
    Escorsell A, Pavel O, Cardenas A, Morillas R, Llop E, Villanueva C, et al. Esophageal balloon tamponade versus esophageal stent in controlling acute refractory variceal bleeding: a multicenter randomized, controlled trial. Hepatology. 2016;63:1957–67.CrossRefGoogle Scholar
  37. 37.
    McCarty TR, Njei B. Self-expanding metal stents for acute refractory esophageal variceal bleeding: a systematic review and meta-analysis. Dig Endosc. 2016;28:539–47.CrossRefGoogle Scholar
  38. 38.
    Vangeli M, Patch D, Burroughs AK. Salvage tips for uncontrolled variceal bleeding. J Hepatol. 2002;37:703–4.CrossRefGoogle Scholar
  39. 39.
    Bari K, Garcia-Tsao G. Treatment of portal hypertension. World J Gastroenterol. 2012;18:1166–75.CrossRefGoogle Scholar
  40. 40.
    D’Amico G, Pagliaro L, Bosch J. Pharmacological treatment of portal hypertension: an evidence-based approach. Semin Liver Dis. 1999;19:475–505.CrossRefGoogle Scholar
  41. 41.
    Gournay J, Masliah C, Martin T, Perrin D, Galmiche JP. Isosorbide mononitrate and propranolol compared with propranolol alone for the prevention of variceal rebleeding. Hepatology. 2000;31:1239–45.CrossRefGoogle Scholar
  42. 42.
    Thiele M, Krag A, Rohde U, Gluud LL. Meta-analysis: banding ligation and medical interventions for the prevention of rebleeding from oesophageal varices. Aliment Pharmacol Ther. 2012;35:1155–65.CrossRefGoogle Scholar
  43. 43.
    Villanueva C, Graupera I, Aracil C, Alvarado E, Minana J, Puente A, et al. A randomized trial to assess whether portal pressure guided therapy to prevent variceal rebleeding improves survival in cirrhosis. Hepatology. 2017;65:1693–707.CrossRefGoogle Scholar
  44. 44.
    Serste T, Melot C, Francoz C, Durand F, Rautou PE, Valla D, et al. Deleterious effects of beta-blockers on survival in patients with cirrhosis and refractory ascites. Hepatology. 2010;52:1017–22.CrossRefGoogle Scholar
  45. 45.
    Leithead JA, Rajoriya N, Tehami N, Hodson J, Gunson BK, Tripathi D, et al. Non-selective beta-blockers are associated with improved survival in patients with ascites listed for liver transplantation. Gut. 2015;64:1111–9.CrossRefGoogle Scholar
  46. 46.
    Monescillo A, Martinez-Lagares F, Ruiz-del-Arbol L, Sierra A, Guevara C, Jimenez E, et al. Influence of portal hypertension and its early decompression by TIPS placement on the outcome of variceal bleeding. Hepatology. 2004;40:793–801.CrossRefGoogle Scholar
  47. 47.
    Garcia-Pagan JC, Caca K, Bureau C, Laleman W, Appenrodt B, Luca A, et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med. 2010;362:2370–9.CrossRefGoogle Scholar
  48. 48.
    Halabi SA, Sawas T, Sadat B, Jandali A, Halabi HA, Halabi FA, et al. Early TIPS versus endoscopic therapy for secondary prophylaxis after management of acute esophageal variceal bleeding in cirrhotic patients: a meta-analysis of randomized controlled trials. J Gastroenterol Hepatol. 2016;31:1519–26.CrossRefGoogle Scholar
  49. 49.
    Zheng M, Chen Y, Bai J, Zeng Q, You J, Jin R, et al. Transjugular intrahepatic portosystemic shunt versus endoscopic therapy in the secondary prophylaxis of variceal rebleeding in cirrhotic patients: meta-analysis update. J Clin Gastroenterol. 2008;42:507–16.CrossRefGoogle Scholar
  50. 50.
    Wang Q, Lv Y, Bai M, Wang Z, Liu H, He C, et al. Eight millimetre covered TIPS does not compromise shunt function but reduces hepatic encephalopathy in preventing variceal rebleeding. J Hepatol. 2017;67:508–16.CrossRefGoogle Scholar
  51. 51.
    Chen S, Li X, Wei B, Tong H, Zhang MG, Huang ZY, et al. Recurrent variceal bleeding and shunt patency: prospective randomized controlled trial of transjugular intrahepatic portosystemic shunt alone or combined with coronary vein embolization. Radiology. 2013;268:900–6.CrossRefGoogle Scholar
  52. 52.
    Buechter M, Kahraman A, Manka P, Gerken G, Dechene A, Canbay A, et al. Partial spleen embolization reduces the risk of portal hypertension-induced upper gastrointestinal bleeding in patients not eligible for TIPS implantation. PLoS One. 2017;12:e0177401.CrossRefGoogle Scholar
  53. 53.
    Riemenschneider T, Bermel RE, Hirner A. Results of devascularization surgery of the gastroesophageal junction in recurrent hemorrhage of esophageal and fundus varices. Zentralbl Chir. 1994;119:291–7.PubMedGoogle Scholar
  54. 54.
    Thomas PG, D’Cruz AJ. Distal splenorenal shunting for bleeding gastric varices. Br J Surg. 1994;81:241–4.CrossRefGoogle Scholar
  55. 55.
    Merli M, Nicolini G, Angeloni S, Gentili F, Attili AF, Riggio O. The natural history of portal hypertensive gastropathy in patients with liver cirrhosis and mild portal hypertension. Am J Gastroenterol. 2004;99:1959–65.CrossRefGoogle Scholar
  56. 56.
    Kim MY, Choi H, Baik SK, Yea CJ, Won CS, Byun JW, et al. Portal hypertensive gastropathy: correlation with portal hypertension and prognosis in cirrhosis. Dig Dis Sci. 2010;55:3561–7.CrossRefGoogle Scholar
  57. 57.
    Primignani M, Carpinelli L, Preatoni P, Battaglia G, Carta A, Prada A, et al. Natural history of portal hypertensive gastropathy in patients with liver cirrhosis. The New Italian Endoscopic Club for the study and treatment of esophageal varices (NIEC). Gastroenterology. 2000;119:181–7.CrossRefGoogle Scholar
  58. 58.
    Kouroumalis EA, Koutroubakis IE, Manousos ON. Somatostatin for acute severe bleeding from portal hypertensive gastropathy. Eur J Gastroenterol Hepatol. 1998;10:509–12.CrossRefGoogle Scholar
  59. 59.
    Bruha R, Marecek Z, Spicak J, Hulek P, Lata J, Petrtyl J, et al. Double-blind randomized, comparative multicenter study of the effect of terlipressin in the treatment of acute esophageal variceal and/or hypertensive gastropathy bleeding. Hepato-Gastroenterology. 2002;49:1161–6.PubMedGoogle Scholar
  60. 60.
    Herrera S, Bordas JM, Llach J, Gines A, Pellise M, Fernandez-Esparrach G, et al. The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in patients admitted for GI hemorrhage. Gastrointest Endosc. 2008;68:440–6.CrossRefGoogle Scholar
  61. 61.
    Smith LA, Morris AJ, Stanley AJ. The use of hemospray in portal hypertensive bleeding; a case series. J Hepatol. 2014;60:457–60.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Gastroenterology, Hepatology, Endocrinology and Nutritional MedicineParacelsus Medical UniversityNurembergGermany

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