Table of Contents
Include in assessment
- Examination: ensure you look for signs of common causes (e.g. chronic/decompensated liver disease) and do PR exam (for melaena)
- Bloods: G&S/crossmatch, FBC (blood loss), U&Es (↑urea in GI bleeds), LFTs (varices risk), clotting (coagulopathy common in liver disease), glucose
- Catheterise (monitor UO)
- CXR and AXR once stable (e.g. for aspiration, obstruction)
- OGD
- Observations: check regularly
ABCDE Management
- Follow usual ABCDE approach
- IV fluid resuscitation (aim for systolic blood pressure ~100)
- In massive blood loss, transfuse blood, FFP and platelets as per local massive haemorrhage protocol
- Blood transfusion if Hb <7g/L in variceal bleed, <8g/L in non-variceal bleed, or shock
- The patient must be haemodynamically stable before endoscopy
Specific treatment
- Acute variceal bleed (suggested by history/signs/results consistent with chronic liver disease or portal hypertension):
- Terlipressin
- Prophylactic IV antibiotics
- Endoscopic intervention (variceal band ligation)
- Non-variceal bleed (e.g. peptic ulcer, Mallory-Weiss tear, oesophagitis):
- IV proton pump inhibitor
- Endoscopic intervention (adrenaline injection, clips, or thermocoagulation)
- In all patients:
- Keep NBM
- Transfuse as above
- Correct any clotting abnormalities
- On warfarin: prothrombin complex concentrate + vitamin K
- On direct oral anticoagulant: Idarucizumab for dabigatran; Andexanet alfa for apixaban/rivaroxaban; consider prothrombin complex concentrate for others/if not available
- ↓Platelets <50×109/L: platelet transfusion
- ↑INR (not due to warfarin): vitamin K (if INR ≥1.5) ± FFP (if INR ≥2)
- ↓Fibrinogen <1g/L: cryoprecipitate
- Stop any antiplatelets or anticoagulants
- Treat any concurrent issues, e.g. encephalopathy, alcohol withdrawal
- Other interventions that are less commonly used
- Balloon tamponade with Sengstaken-Blakemore tube
- Interventional radiology (embolisation)
- Surgical intervention
- Transjugular Intrahepatic Portosystemic Shunt (for resistant varices)
Scoring systems
Glasgow-Blatchford score (pre-endoscopy)
- Assesses likelihood patient will need intervention
- Score 0 = can manage as outpatient; score ≥1 = manage as inpatient)
- Takes into account haemoglobin, urea, SBP, sex, HR, presence of melaena, recent syncope, history of liver disease or heart failure (Blatchford et al. 2000)
Rockall score (post-endoscopy)
- Mortality risk assessment
- Score ≤2 = good prognosis; score >8 = high mortality risk
- Takes into account age, shock, comorbidities, diagnosis and evidence of bleeding (Rockall et al. 1996)
Preventing further bleeding
Treat the cause/reduce the risk of re-bleeding:
- Oesophageal varices
- Carvedilol (β-blocker that reduces portal venous pressure)
- Variceal banding
- Transjugular Intrahepatic PortoSystemic Shunt
- Liver transplant
- Peptic ulcer
- Proton pump inhibitor
- H. pylori eradication if +ve
- Avoid precipitants, e.g. NSAIDs
Test your knowledge with some questions
How does terlipressin work in a variceal bleed?
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What is a TIPS? How is it undertaken and how does it work?
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A patient has a TIPS and then becomes confused. What has happened? What is your initial management?
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