What’s new in ICU management of patients with portal hypertension-related bleeding?

Abstract

Portal hypertension-related bleeding is a severe and frequent complication in cirrhotic patients. Its management is now clearly codified in the Baveno guidelines which are regularly updated (on top of European and American guidelines).

Acute variceal bleeding treatment combines vasoactive drugs for two to five days, prophylactic antibiotics for seven days, hepatic encephalopathy prophylaxis, as well as early upper gastrointestinal endoscopy (< 12h) for variceal treatment (elastic band ligation and/or tissue adhesive injection). Failure to control bleeding must lead to salvage TIPS (Transjugular Intrahepatic Portosystemic Shunt) discussion, after esophageal tamponade (balloon or stent).

Pre-emptive TIPS within 72h must systematically be considered in high-risk patients (Child-Pugh B > 7 with active endoscopic bleeding or Child-Pugh C < 14) to reduce rebleeding and mortality.

Following the acute bleeding episode, secondary prophylaxis combines non-selective betablockers and recurrent endoscopic treatments (in patients for which no TIPS was implemented).

Liver transplantation must be discussed in certain cases of refractory bleeding or early relapse after TIPS implantation.