Treatment of Chronic Liver Failure in Liver Cirrhosis with Portal Hypertension and Acute Variceal Haemorrhage
Clinical Scenario
This protocol covers chronic liver failure arising in a patient with established liver cirrhosis and portal hypertension, complicated by acute upper gastrointestinal bleeding due to acute variceal haemorrhage. Acute variceal haemorrhage must be suspected in any cirrhotic patient presenting with upper acute GI bleeding; treatment should be initiated as soon as bleeding is clinically confirmed, without waiting for endoscopic confirmation.
Treatment Approach (Overview)
Management combines prompt volume resuscitation using a restrictive transfusion strategy, vasoactive drug therapy initiated before endoscopy, antibiotic prophylaxis, and timed endoscopic intervention — all delivered within a structured early time window.
Full agent selection, sequencing, decision criteria, and targets are in the complete protocol.
Clinical Goals
Primary objective is control of bleeding, achieved in approximately 85% of cases, with haemoglobin maintained within a defined target range throughout the acute episode.
References
DOI: 10.1016/j.jhep.2018.03.024
- Acute variceal haemorrhage (AVH) must be suspected in any cirrhotic patient presenting with upper acute GI bleeding and treatment should be started as soon as bleeding is clinically confirmed, regardless the lack of confirmation by upper endoscopy.
- Volume replacement should be initiated promptly to restore and maintain haemodynamic stability (III;1).
- A restrictive transfusion strategy is recommended in most patients with a haemoglobin threshold for transfusion of 7 g/dl and a target range of 7–9 g/dl (I;1).
- Vasoactive drug therapy should be initiated as soon as acute variceal bleeding is suspected, and before endoscopy. Terlipressin, somatostatin or octreotide are accepted options. In patients with acute variceal bleeding drug therapy should be administered for three to five days (I;1).
- The combination of vasoactive drugs and ligation is recommended as the first therapeutic option in acute variceal bleeding (I;1).
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