How to treat and prevent bleeding in cirrhosis ??? - What does American association of study of liver diseases says ??

How to manage Cirrhosis Complications?? Part 1- gastrointestinal bleeding.

We have discussed about when liver transplantation is required for cirrhosis.

Now I will try to describe how to tackle various complication of cirrhosis wither without transplant or if you are in the waiting list for transplant.

Today I will take on gastrointestinal bleeding.

Why gastrointestinal bleeding occurs in cirrhosis?

Blood from gastrointestinal tract first goes to liver because nutrients absorbed from intestines needs to be digested to release energy and harmful substance from it needs to be removed. Liver does both the functions. Now in cirrhosis due to microscopic changes there is increase resistance to this blood so there are backpressure on the vessels so these blood vessels gets dilated. Mostly it is seen in lower end of esophagus. (Esophageal varices)When pressure increase beyond certain level these blood vessels burst and cause bleeding which can be life threatening.

Remember if you have survived one episode of bleeding chances of re bleeding is as high as 60%.

So if you are encountering these bleeding repeated time only definitive therapy is remove that resistance and most definitive therapy for it is change the diseased liver. i.e Transplantaion.

But there are other ways to tackle it particularly if rests of the liver functions are good or you are waiting for transplant.

These varices (dilated vessels in esophagus etc is generally managed by durgs like Inderal, endoscopic banding, Tranjugular Intrahepatic Porto systemic Shunts or (TIPS OR TIPSS).

But How to use them in different situation is described wonderfully by American Association of Study of Liver Diseases.

I will mention guidelines given by American Association of study of Liver diseases for managing these cases.

A.    PATIENTS WITH CIRRHOSIS AND NO VARICES:

1.     In patients with cirrhosis who do not have esophageal varices, nonselective β -blockers (medical drugs like Inderal etc.) cannot be recommended to prevent their development.

2.     In patients who have compensated cirrhosis (Preserved Liver function )and no varices on the initial endoscopy, it should be repeated in 3 years. If there is evidence of hepatic decompensation, (abnormal liver function )EGD should be done at that time and repeated annually.

B.    PATIENTS WITH CIRRHOSIS AND SMALL VARICES THAT HAVE NOT

BLED

1.  In patients with cirrhosis and small varices that have not bled but have criteria for increased risk of hemorrhage (Child B/C or presence of red wale marks on varices),

nonselective β -blockers (Inderal) should be used for the prevention of first variceal hemorrhage.

2. In patients with cirrhosis and small varices that have not bled and have no criteria for increased risk of bleeding, β -blockers can be used, although their long-term benefi t

has not been established.

3. In patients with small varices that have not bled and who are not receiving β -blockers, endoscopy should be repeated in2 years. If there is evidence of hepatic decompensation, EGD should be done at that time and repeated annually (Class I, Level C). In patients withsmall varices who receive β -blockers, a follow-up EGD is not necessary.

C.   PATIENTS WITH CIRRHOSIS AND MEDIUM/LARGE VARICES THAT HAVE NOT BLED.

1.  In patients with medium/large varices that have not bled but have a high risk of hemorrhage (Child B/C

or variceal red wale markings on endoscopy), nonselective β -blockers (inderal) or endoscopic banding may be recommended for the prevention of first variceal hemorrhage.

2.  In patients with medium/large varices that have not bled and are not at the highest risk of hemorrhage (Child A patients and no red signs), nonselective β –blockers (Inderal etc.) are preferred and banding should be considered in patients with contraindications or intolerance or non-compliance to β –blockers (Inderal etc.)

3. If a patient is placed on a nonselective β -blocker, it should be adjusted to the maximal tolerated dose;

follow-up surveillance endoscopy is unnecessary. If a patient is treated with banding, endoscopy should be repeated every 1– 2 weeks until obliteration with the first surveillance, endoscopy performed 1– 3 months after obliteration and then every 6– 12 months to check for variceal recurrence.

D.   PATIENTS WITH CIRRHOSIS AND AN ACUTE(emergency, sudden) EPISODE OF VARICEAL HEMORRHAGE

1.  Acute bleeding in a patient with cirrhosis is an emergency that requires prompt attention with intravascular volume support and blood transfusions, being careful to maintain a hemoglobin of ∼ 8 g/dL .

2. Short-term (maximum 7 days) antibiotic prophylaxis should be instituted in any patient with cirrhosis and  bleeding.

3. Medical treatment (somatostatin or its analogues

octreotide and vapreotide; terlipressin) shouldbe initiated as soon as variceal hemorrhage is suspected

and continued for 3– 5 days after diagnosis is confirmed

4. Endoscopy, performed within 12 hours, should be used to make the diagnosis and to treat variceal hemorrhage, either with banding or sclerotherapy.

5. TIPS is indicated in patients in whom hemorrhage from esophageal varices cannot be controlled or in whom bleeding occurs again despite combined pharmacological and endoscopic therapy

E.    PATIENTS WITH CIRRHOSIS WHO HAVE RECOVERED FROM ACUTE VARICEAL HEMORRHAGE:

Remember chances of rebleeding as as high as 60% once you have upper gastrointestinal bleeding with chances of death are as high as 33 % due to bleeding.

1. Patients with cirrhosis who survive an episode of active variceal bleeding should receive therapy to prevent recurrence of variceal bleeding (secondary prophylaxis)

2. Combination of nonselective β -blockers plus banding is the best option for secondary prophylaxis of variceal hemorrhage (Class I, Level A).

3. The nonselective β -blocker should be adjusted to the maximal tolerated dose. EVL should be repeated every 1– 2 weeks until obliteration with the first surveillance

endoscopy performed 1– 3 months after obliteration and then  every 6– 12 months to check for variceal recurrence.

4. TIPS should be considered in patients who are Child A or B who experience recurrent variceal hemorrhage despite combination pharmacological and endoscopic

therapy. In centers where the expertise is available, surgical shunt can be considered in Child A patients.

5. Patients who are otherwise transplant candidates should be referred to a transplant center for evaluation.

As you can see mentioned in last guideline last option is transplant but before that they mention tips.

Now what is TIPS?

It is an radiological procedure where radiologist creat a communication between vessels that are carrying the blood to liver and vessels which are coming out of the liver so that practically hey bypass liver.

So that resistance is gone and bleeding can be prevented. Only disadvantage of this procedure is liver is bypassed so that liver can no longer remove harmful substance from the blood that also contains toxic substance from the blood. These substances can reach to brain and cause mental status changes known as encephalopathy.

These joining of blood vessels can also be done by various surgical options. But in the era of transplant they are less preferred as they can difficult in subsequent transplantation. If transplant is not the option and any how you have to manage bleeding then there are few surgical procedures but they should be considered as a last option.

 Trans jugular intrahepatic porto systemic shunt or (TIPS)