Hepatic Failure/GI/Endocrine Emergencies
| (c) | When used without therapeutic endoscopy, octreotide is only marginally beneficial (i.e., |
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reduction of packed red blood transfusion by 0.7 unit with no benefit on rebleeding or
mortality).
| (d) | Compared with endoscopic therapy alone, a somatostatin analog combined with |
|---|
endoscopic therapy is associated with improved initial control of bleeding (relative risk
[RR] 1.12; 95% CI, 1.02β1.23) and hemostasis at 5 days (RR 1.28; 95% CI, 1.18β1.39) with
no difference in mortality or serious adverse events.
| (e) | Patients should be monitored for bradycardia and hyperglycemia during octreotide |
|---|
infusion.
| (f) | For patients in whom a TIPS is performed successfully, octreotide can be discontinued. |
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ii.
Vasopressin infusion is not recommended for variceal UGIB because of the high incidence
of adverse events (cardiac, peripheral, and bowel ischemia) with doses necessary to reduce
splanchnic blood flow (0.2β0.8 unit/minute).
iii.
Because of the high incidence of peptic ulcerβrelated UGIB, high-dose PPI should be initiated,
even when variceal UGIB is suspected, until the diagnosis of variceal UGIB is confirmed.
| (a) | There is no evidence that high-dose PPI therapy reduces the risk of rebleeding after |
|---|
endoscopic therapy for variceal UGIB.
iv.
Patients with cirrhosis, with or without ascites, and UGIB (whether variceal or non-variceal)
should be initiated on short-term prophylactic antibiotics.
| (a) | Antibiotics are associated with a lower risk of infection, lower risk of rebleeding, shorter |
|---|
length of stay, and higher survival rates.
| (b) | Guidelines recommend therapy with ceftriaxone 1 g daily. Ceftriaxone is preferred to |
|---|
fluoroquinolones because of the high prevalence of fluoroquinolone resistance. Ceftriaxone
should be considered for discontinuation when hemorrhage has resolved and octreotide is
discontinued.
| (c) | Prophylactic antibiotic therapy should be continued for no more than 7 days. |
|---|
For patients in whom a TIPS is not performed, a nonselective Ξ²-blocker (propranolol, nadolol,
or carvedilol) should be initiated once octreotide is discontinued unless the patientβs heart rate
or blood pressure prohibit Ξ²-blocker therapy.
vi.
Simvastatin may be added to standard therapy in patients with cirrhosis and variceal bleeding.
| (a) | A randomized placebo-controlled trial showed that simvastatin did not reduce the rate of |
|---|
rebleeding but was associated with decreased mortality in patients with Child-Pugh class
A and B cirrhosis.
| (b) | Patients should be monitored closely for clinical signs and symptoms of rhabdomyolysis. |
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Treatment of H. pylori infection is beyond the scope of this chapter; however, a 14-day treatment
should be given to all patients with suspected or diagnosed infection, and eradication should be
confirmed 4 weeks after therapy.
Rescue therapies
For patients in whom endoscopic therapy has failed or who are not candidates for endoscopy,
angiographic intervention (typically selective arterial embolization) may be required.
For variceal UGIB, balloon tamponade may be used as a temporizing method (maximum 24 hours)
while definitive therapy is planned.
TIPS is indicated in patients in whom hemorrhage from esophageal varices cannot be controlled
or in whom bleeding recurs, despite pharmacologic and endoscopic therapy. Patients with Child-
Turcotte-Pugh class C cirrhosis or Child-Turcotte-Pugh class B with bleeding on endoscopy may
be considered for TIPS within 72 hours.