JUST NOTES STILL UNDER CONSTRUCTION
Acute variceal bleeding is one of the most common and severe complications of cirrhosis, and such patients typically present to the ED. ED management:
A restrictive blood transfusion is associated with a reduction in further bleeding and rebleeding, a reduction in complication rate, and increased survival. PRBC transfusion should be done conservatively to obtain a target hemoglobin level between 7 - 8 g/dl (of course, other factors such as co-morbidities, age, and hemodynamic status should be considered on an individual basis).
Antibiotic prophylaxis is an integral part of therapy for patients with cirrhosis presenting with UGI bleeding as the use of antibiotics has been shown to reduce both the risk of rebleeding and mortality. Quinolones are frequently used but in high-risk patients (> 2 of the following: ascites, jaundice, malnutrition, or encephalopathy) ceftriaxone (1 g/d for 7 days) has been shown to be superior.
Vasoactive drugs (e.g. octreotide) should be initiated as soon as variceal bleeding is suspected before endoscopy. Vasoactive drugs cause splanchnic vasoconstriction, thereby decreasing portal pressure and reducing or stopping variceal bleeding.
References:
(1) Cremers I, et al. Therap Adv Gastroenterol Sep 2014; 7(5): 206-216.
(2) Intagliata NM, et al. Clinical Liver Disease 2014; 3(6): 114-117.
(3) Garcia-Pagan JC, et al. Semin Respir Crit Care Med 2012;33:46-54.
(4) de Franchis R, et al. J of Hepatology 2010;53: 762-768.