Patients who are hospitalized with cirrhosis are in trouble. They may have hepatic encephalopathy leading to impaired mentation and possible coma. They may have acute kidney injury that requires a liver transplant. They may have portal hypertension leading to ascites and spontaneous bacterial peritonitis. And they may have potentially fatal variceal bleeding.
“Acute variceal bleeding is one of the few medical emergencies we see in hepatology,” said Catherine Frenette, MD, medical director of liver transplantation and director of the hepatocellular carcinoma program at the Scripps Center for Organ Transplant, La Jolla, CA. “Our immediate goal is to stop the bleeding and keep the patient from dying over the next six weeks. Long-term goals are to prevent recurrence of bleeding and prevent death from liver disease.”
Dr. Frenette discussed the evidence-based management of hospitalized cirrhotic patients during an AASLD Clinical Symposium Monday morning at DDW®.
Patients with acute variceal hemorrhage need aggressive ICU care and urgent endoscopic evaluation, Dr. Frenette said. Mortality from acute variceal bleeding has declined from 65 percent in the 1980s to about 20 percent today, she said. Two-thirds of mortality is related to infection, renal failure and liver failure.
For patients with decompensated cirrhosis, a variceal hemorrhage alone increases the risk of death over the next five years by 20 percent. Add ascites with or without hepatic encephalopathy and the risk of death rises to more than 80 percent over the next five years.
In 2016, AASLD released new practice management guidelines on “Portal Hypertensive Bleeding in Cirrhosis.” In addition to immediate admittance to the ICU or a monitored bed, patients need immediate volume resuscitation to maintain hemodynamic stability and early imaging in case a transjugular intrahepatic portosystemic shunt (TIPS) procedure is required. Clinicians should have a low threshold for intubation to protect the airway for endoscopy, Dr. Frenette said.
Vasoactive agents should be started as early as possible, even before endoscopy. Vasopressin is the most potent agent, but can have cardiovascular effects. It should be used with IV nitroglycerin to maintain systolic blood pressure above 9 mmHg. Other potential agents include octretide, somatostatin and terlipressin.
Transfusions should be restricted to patients whose hemoglobin falls below 7g/dL, Dr. Frenette said. A more intensive strategy calling for transfusion when hemoglobin falls below 9 g/dL is associated with significantly worse survival, particularly in patients with cirrhosis.
The international normalized ratio (INR) is not a reliable indicator of coagulopathy in cirrhosis, Dr. Frenette cautioned, and INR should not be corrected with either fresh frozen plasma or Factor VIIa. There are no recommendations for or against platelet transfusion.
There are very strong recommendations for antibiotics in all patients, regardless of liver disease stage. Ceftriaxone is the first choice for patients at high risk due to advanced cirrhosis, patients already on quinolone prophylaxis or in institutions with a high prevalence of quinolone-resistant bacteria.
Endoscopic therapy should be performed as early as possible and not more than 12 hours after presentation. Ligation is preferred over sclerotherapy.
Guidelines also recommend early TIPS for some patients, including those with elevated risk or ongoing bleeding despite vasoactive therapy. TIPS within 72 hours of admission is associated with lower mortality, shorter length of stay and lower readmission rates. If TIPS is successful, vasoactive drugs can be discontinued
Secondary prevention to minimize rebleeding is indicated for all patients with variceal bleeding, Dr. Frenette said. Beta blockers and endoscopic variceal ligation every one to four weeks to eradicate all variceals are most effective.