End-Stage Liver Disease and Variceal Bleeding

Abstract

Cirrhosis occurs when damage to the liver results in scar tissue (hepatic fibrosis), affecting liver function. By the time cirrhosis is diagnosed or suspected based on stigmata of chronic liver disease (e.g., spider angiomas, jaundice, pruritis, palmar erythema) and laboratory abnormalities, approximately 30–40% of patients will have varices. Of those without varices at the time of diagnosis, another 10–15% will develop varices each year. Despite its probable safety based on small retrospective series, the decision to place an NGT for aspiration or lavage requires a careful assessment of the potential risks (e.g., bleeding, pain, aspiration, unclear prognostic and outcome value) and benefits (e.g., localization of bleed and assessment of active bleeding) of the procedure. Gastrointestinal bleeding in patients with cirrhosis is common and carries a high mortality rate of approximately 15–30%. Risk factors associated with early re-bleeding and poor outcomes include severe initial bleeding as defined by a hemoglobin less than 8 g/dL, gastric variceal bleeding, thrombocytopenia, encephalopathy, alcohol-related cirrhosis, large varices, and active bleeding during endoscopy. Antibiotics have a proven benefit in variceal bleeding with decreased morbidity and mortality. Vasoactive medications such as terlipressin a synthetic vasopressin not available in the United States, octreotide, and somatostatin have all been studied and found to have varied benefits in the treatment of variceal bleeding.