Cirrhosis - Bleeding Episodes

Highlights	Complications	Encephalopathy
Introduction	Diagnosis	Ascites
Causes	Treatment	Bleeding Episodes
Risk Factors	Lifestyle Changes	Resources
Symptoms	Abdominal Infections	References

Bleeding Episodes

Preventing an Initial Bleeding Episode. About half of patients with mild to moderate cirrhosis have esophageal varices (abnormal blood vessels in the esophagus). In such patients the risk for bleeding within two years is as high as 35%. Bleeding is fatal in half of these patients. In general, experts now recommend preventive drugs in such patients, even if they have not been screened with endoscopy -- the procedure needed to actually detect varices. Beta-blockers are the only medications to date that have some preventive effects, but others are under investigation.

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Guidelines for Treating Bleeding Episodes. The physicians should first be certain that bleeding is caused by portal hypertension and ruptured varices and not by other conditions. For example, cirrhosis patients are also at higher than average risk for bleeding peptic ulcers.

Saline or Ringers solution (a fluid and electrolyte replenisher) followed by red blood cells and plasma is administered immediately to replace lost blood.

The next step is to immediately achieve a normal blood flow (hemostasis) in order to stop the current bleeding episode and prevent early recurrence, which typically occurs three to five days after a bleeding episode.

In general it is a two-pronged approach using drugs and endoscopy procedures.

Drugs. The patient should be given drugs to reduce portal pressure and blood flow, typically octreotide or vasopressin.
Endoscopy. Endoscopy employs an insertion of a thin tube containing a tiny camera and surgical instruments in order to make repairs. Endoscopic sclerotherapy is the most common procedure. Emergency sclerotherapy is often used as first-line therapy for variceal bleeding, but a major 2002 analysis of the existing evidence suggests that it is no more effective than agents used to stop bleeding and it has potentially serious adverse effects.

A combination of drugs and endoscopy is the best approach for stopping bleeding compared to endoscopy alone. It is not clear if there is any difference in long-term survival however.

Prevent Bleeding Recurrence. Rebleeding is common after an episode. Investigation is ongoing concerning the most cost-efficient ways for preventing recurrence. At this time, beta-blockers are the best treatments available, although they are not effective in many patients. Drug combinations and endoscopic procedures are under investigation to determine if they offer any additional benefits.