Blood pressure is unreliable indicator of volume status
Hematocrit does not reflect acute blood losses
Place twp large bore i.v.’s and/or a central venous catheter
Colloid or crystalloid titrated to parameters of perfusion
Cross-matched or O negative blood can be used
Endotracheal intubation prior to endoscopy for:
Altered mental status, severe agitation
Respiratory distress or depression
Hierarchal Treatment for Variceal Bleeding Pharmacologic Endoscopic Radiologic shunt TIPSS Surgical Shunt Balloon Tamponade Pharmacologic and endoscopic therapy are the usual 1 st and 2 nd interventions
Abdominal distension : From endoscopic air insufflation, retained luminal blood, and increased ascites from resuscitation. This can even progress to abdominal compartment syndrome with associated respiratory compromise, hypotension, oliguria, and acidosis. Nasogastric decompression may partially alleviate this problem .
Worsening encephalopathy : This may occur due to gastrointestinal passage of blood, hepatic hypoperfusion (“shock liver), and accumulation of sedative medication.
Recurrent bleeding : More likely to recur in advanced cirrhosis. Incidence can be reduced with a 5-day course of octreotide post banding and long term use of a non-selective beta blocker (propanol, naldolol).
Infection : Spontaneous bacterial peritonitis is 3-5x higher following variceal hemorrhage due to occult bacteremia and ascites seeding. Antimicrobial prophylaxis (quinolone, beta-lactam) reduces the incidence of SBP significantly.
12 mm diameter) which joins the hepatic and portal veins
Target gradient (HV-PV) < 12 mmHg
Restores hepatopedal flow
Decompression of varices
Summary of Trials Comparing TIPSS to Endoscopic Therapy for Variceal Bleeding Stanley. Lancet. 1997;350(9086):1235-1239. Generally, higher rates of rebleeding were more common after Endoscopy treatment, while encephalopathy rates were higher in the TIPSS groups
Intraperitoneal bleeding due to perforation of the hepatic capsule, hepatic, or portal veins
Acute right heart failure due to increased venous return to right heart
Later complications include recurrent bleeding due to TIPSS stenosis or thrombosis, infection, and hepatic encephalopathy.
Conditions Which May Contraindicate TIPSS This venogram shows an occlusive thrombus of the portal vein, which may make safe TIPSS placement impossible. This abdominal CT demonstrates a large hypodense hepatic lesion due to hepatocellular carcinoma in a very shrunken cirrhotic liver. Other contraindications include hepatic vein occlusion, heart failure or pulmonary hypertension, biliary obstruction, and poorly controlled systemic infection.
The distal splenorenal shunt (Warren shunt) procedure is generally reserved for Child’s A or B cirrhotics.
Consider in patients with bleeding refractory to pharmacologic, endoscopic, and radiologic treatment.
Complications include shunt thrombosis, infection, and worsening encephalopathy.
30-day mortality is close to 80% in Child’s C patients requiring emergency shunt surgery.
Relative Effectiveness of Available Therapies for the Prevention of Recurrent Variceal Bleeding Beta-blockers are the single most effective and safest strategy to prevent the recurrence of variceal Bleeding. More aggressive strategies such as banding, TIPSS, or shunt surgery may decrease bleeding but are associated with higher risks and costs. Sharara A, et al. N Engl J Med. 2001.
Complicated ascites may be the principal reason for care admission but is frequently co-associated with intensive hemorrhage, renal failure, and/or hepatic encephalopathy.
Common complications of ascites include:
Diuretic-refractory ascites - defined as unresponsiveness to sodium restriction and high-dose diuretics (400 mg/day spironolactone and 160 mg/day furosemide) OR rapid recurrence after therapeutic paracentesis
Tense ascites - this may result in the development of:
- Abdominal compartment syndrome with impaired venous return causing hypotension, impaired renal perfusion causing oliguria and reduced hepatosplanchic perfusion
- Respiratory compromise may occur due to impaired diagphagmatic contractility and/or hydrothorax due to the passage of ascites into the pleural space
Acute impairment in renal function defined by doubling of initial serum creatinine above 2.5 mg/dl or a 50% reduction of the initial 24-hour creatinine clearance to a level lower than 20 ml/min in less than two weeks. Mortality is as high as 90% after 2 - 4 weeks
Type 2 HRS:
Stable or slowly progressive impairment in renal function not meeting the above criteria. Associated with better survival than Type 1 HRS.
Hepatorenal Syndrome Pere Ginès, et al. N Engl J Med. 2004;350:1646-1654.
Administration of one of the following drugs or drug combinations can be considered:
Norepinephrine 0.5 - 3.0mg/h intravenously
Midodrine 7.5 mg three times daily increased to 12.5 mg three times daily if needed in combination with octreotride 100 g subcutaneously three times daily, increased to 200 g three times daily if needed
Concomitant adminstration of albumin 1 g/kg intravenously on day one, followed by 20 - 40 g daily
This treatment is given for 5 to 15 days.
End point of the treatment is reduction of serum creatinine to < 1.5 mg/dl
Vasoconstrictor Studies in HRS Or – orlipressin NE – norepinephrine Te - terlipressin OC - octreotide Mi - midodrine A - albumin These results, although encouraging, need to be validated by a large, prospective randomized trial. 30 (18%) 73 (44%) 104 (63%) 165 TOTAL 13 36 58 99 Te ± A Moreau 3 6 10 12 NE + A Duvoux 2 4 4 5 Mi,Oc,A Angeli 5 9 10 13 Te ± A Ortega 2 4 7 12 Te + A Mulkay 2 4 4 7 Or, D, A Gulberg 3 5 7 9 Te + A Uriz - 5 4 8 Or + A Guevara Liver Tx Survival HRS Reversal # Pts Treatment STUDY