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Chapter 6

Emergency Complications of Cirrhosis

Britt Long, MD and Rob Orman, MD
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Discuss emergency department management of patients with complications of cirrhosis.

 

Pearls:

  • The 3 main goals when managing the cirrhotic patient with a GI bleed are hemodynamic resuscitation, stopping the hemorrhage, and preventing complications.

  • The massive transfusion protocol can be followed to guide the use of blood products, but cryoprecipitate may also be needed to replenish fibrinogen.

  • Early GI and/or IR consultation is critical for patients with esophageal variceal hemorrhage.  Temporizing measures to control the bleeding in the ED include vasoactive agents and a balloon tamponade device.

  • A single dose of antibiotics given in the ED can reduce the infection risk (and mortality) for those with esophageal bleeding.

  • ED paracentesis can safely be performed even if a patient has an elevated INR or low platelets.

  • Albumin should be given to cirrhotic patients if greater than 5 liters of ascitic fluid is removed.



  • There are 3 primary management goals when treating the cirrhotic patient with a massive GI bleed:

    • Hemodynamic resuscitation.

      • This is tricky in cirrhotics because they have a rebalance of their hemostatic system.  At baseline they not only have decreased circulating clotting factors, but they also have decreased anticoagulant factors.  These patients are in a balanced state of coagulation, but that state is fragile and can quickly shift to hemorrhage or to thrombosis with minimal stress.

        • Kujovich, Jody L. "Coagulopathy in liver disease: a balancing act." ASH Education Program Book 2015.1 (2015): 243-249. PMID: 26637729

        • Tripodi, Armando, and Pier Mannuccio Mannucci. "The coagulopathy of chronic liver disease." New England Journal of Medicine 365.2 (2011): 147-156.PMID: 21751907

      • Try and optimize hemodynamics before securing the airway.  

        • Establish IV access.

        • Activate your massive transfusion protocol, giving blood, FFP and platelets.

        • Add cryoprecipitate (for its fibrinogen). Each bag of cryo 10-15 cc’s and will raise the fibrinogen approximately 7 mg/dL.  You can empirically give all 10 bags, or you can give 1 unit per every 10 kg of patient body weight. Cryo can be infused quickly and the target fibrinogen level is 150 mg/dL.

      • Place a nasogastric tube (preferably before intubation) to evacuate blood from the stomach.  Alternatively, leave a suction catheter (or two taped together) in the pharynx while attempting intubation to enhance visualization of the cords.

      • Give metoclopramide or erythromycin to push the rest of the blood through the GI tract.

      • Though there’s limited data to support it, some recommend tranexamic acid (TXA) for the cirrhotic with a massive GI bleed.  Cirrhotics can have excess fibrinolysis and TXA can temper this. The dose is 1 gm over 15 minutes.

      • Since cirrhotics have at baseline a lower SBP and MAP, you need to target a combination of end points of perfusion to determine the success of your resuscitation.  This includes assessment of capillary refill time, mental status, general appearance, and blood pressure.

    • Stop the bleeding.

      • Most upper GI bleeds will stop on their own.  The exception is a bleed due to esophageal varices.  Only about half of these stop on their own.

      • For esophageal variceal hemorrhage, there are several options for hemostasis in the ED.

        • Give a vasoactive agent such as vasopressin, somatostatin, or their analogues (octreotide and vapreotide).  

          • The octreotide dose is 50 µg IV bolus followed by a drip.

          • These agents work by lowering portal pressure.

          • A meta-analysis found that vasoactive agents were associated with a significantly lower seven day mortality, improvement in hemostasis, lower transfusion requirements, and a shorter hospital stay.

            • Wells, M., et al. "Meta‐analysis: vasoactive medications for the management of acute variceal bleeds." Alimentary pharmacology & therapeutics 35.11 (2012): 1267-1278. PMID: 22486630

        • Placement of a Sengstaken Blakemore or Minnesota tube as a temporizing measure to control the bleeding.  These devices have gastric and esophageal balloons which are designed to tamponade the bleeding vessels. Familiarize yourself with the device carried in your institution.  These are placed after tracheal intubation.

      • Early GI and/or interventional radiology consultation is critical for definitive management of patients with esophageal variceal bleeding.

    • Prevent and treat complications of the GI bleed.  

      • Give antibiotics early.   

        • 25-65% of patients with an esophageal bleed will develop an infection.  A single dose of an antibiotic given in the ED has a number needed to treat (NNT) of 22 to prevent death and a NNT of 4 to prevent infection.  

          • Ceftriaxone 1 gm and cefotaxime 2 gm IV are both good options.

        • Antibiotics may also help with hemorrhage management since bacterial infections increase the risk of bleeding (or rebleeding) in these patients.  The suspected mechanism includes the release of endogenous heparinoids. Also, endotoxins can raise portal pressure.

          • Thalheimer, U., et al. "Endogenous heparinoids in acute variceal bleeding." Gut 54.2 (2005): 310-311.PMID: 15647203

  • To tap or not to tap.  Which patients with ascites warrant an ED paracentesis?

    • Anyone with new onset ascites.

    • Anyone whose clinical picture raises concern for SBP.

      • When admitting a patient with ascites, it is prudent to do a diagnostic paracentesis to rule out SBP, because sometimes the symptoms don’t match the severity of the disease.  Up to 10% of patients with SBP are asymptomatic.

    • Anyone with severe cardiorespiratory of GI side effects, such as shortness of breath or ileus.

  • How safe is a paracentesis?  Very.

    • Studies show a less than 1% chance of an adverse event or complication due to paracentesis.  The biggest risks are infection and bleeding; these can be minimized by using ultrasound to identify the optimal pocket and to look for blood vessels.

    • For patients with thrombocytopenia or an elevated INR, the procedure can safely be performed without pretreatment with FFP or platelets.

  • For large volume, therapeutic paracentesis, how much fluid can be removed and when is it necessary to give albumin?

    • Most patients will need up to or over 5 liters removed to alleviate symptoms.

    • The American Association for the Study of Liver Disease (AASLD) guideline recommends giving albumin if greater than 5 liters are removed.  An albumin infusion of 6-8 grams per liter of fluid removed appears to improve survival.

      • A 2012 meta-analysis showed that albumin reduced the incidence of post paracentesis circulatory dysfunction, hyponatremia, and mortality.

      • Bernardi, Mauro, et al. "Albumin infusion in patients undergoing large‐volume paracentesis: a meta‐analysis of randomized trials." Hepatology 55.4 (2012): 1172-1181. PMID: 22095893

    • Some patients with SBP should receive albumin after paracentesis.   SBP is a risk factor for renal failure; it can develop in up to 40% of cirrhotics.  The recommendations are to give albumin if the patient’s creatinine is greater than 1 mg/dL (88.4 µmol/L), if the BUN is greater than 30 mg/dL (10.7 mmol/L), or if the total bilirubin is greater than 4 mg/dL (68.4 µmol/L) The dose is 1.5 gm/kg.

  • When sending ascites fluid to the lab, what tests should we order?  

    • The most important things to focus on are the polymorphonuclear count and the culture.  A PMN count of ≥250 cells/mm3 is diagnostic of SPB.

    • It is important to put an adequate amount of fluid in each blood culture bottle.  By putting at least 20 cc of ascitic fluid into two separate culture bottles, you can increase your yield by 25%.

    • Do not delay performing a diagnostic paracentesis.  Each hour of delay increases mortality by 3%.

    • The AASLD guidelines recommend cefoxitin first-line for SBP.  Ceftriaxone is also an option.

 

This podcast and blog post do not reflect the views or opinions of the U.S. government, Department of Defense or its Components, U.S. Army, U.S. Air Force, or SAUSHEC EM Residency Program

 

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