Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets (hemodynamic, neurologic, respiratory) and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Resuscitate with restrictive transfusion (Hgb threshold ~7 g/dL); correct coagulopathy prudently.
- Start octreotide and ceftriaxone; consult GI/hepatology.
- Perform early EGD with band ligation; use balloon tamponade/SEMS as bridge if uncontrolled.
- Assess for early TIPS in high‑risk patients; plan secondary prophylaxis with nonselective β‑blocker + serial banding.
Clinical Synopsis & Reasoning
Portal hypertensive bleeding in cirrhosis requires early vasoactive drugs, prophylactic antibiotics, and endoscopic band ligation; use restrictive transfusion strategy and consider TIPS for refractory or high‑risk cases.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| CBC, INR, fibrinogen, type & cross | Bleed severity/MTP | Anemia/coagulopathy | Serial Hgb |
| Diagnostic/therapeutic EGD | Source control | Esophageal varices | Band ligation preferred |
| Ultrasound/CT (post‑stabilization) | Etiology/portal HTN | Cirrhosis, portal vein thrombosis | — |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Octreotide 50 µg bolus → 50 µg/h infusion | Vasoactive | Hours | Reduce portal flow | Continue 3–5 days |
| Ceftriaxone 1 g IV daily (7 days) | Antibiotic prophylaxis | Hours | Reduces infections/rebleeding | Adjust by allergy/local resistance |
| Proton pump inhibitor (peri‑endoscopy) | Gastric protection | Hours | Adjunct for post‑banding ulcers | Not primary therapy |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- AASLD/Baveno VII guidance on portal hypertensive bleeding — Link