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.

Keywords: cirrhosis; management; upper gastrointestinal bleeding.

Conflict of interest statement

Conflict of interest statement: The authors declare that there is no conflict of interest.

Figures

Figure 1.

Active bleeding from a gastric varix.

Figure 2.

Band ligation of esophageal varices.

Figure 3.

Treatment algorithm for upper gastrointestinal bleeding in patients with cirrhosis. EVL, endoscopic variceal ligation; ; GAVE, gastric antral vascular ectasia; GOV, gastroesophageal varices; ICU, intensive care unit; MW: Mallory–Weiss; PUD, peptic ulcer disease; TIPS, transjugular intrahepatic portosystemic shunt; VEB, variceal esophageal bleeding.