Clinical scenario | Medications to decrease portal hypertension | Management of anemia/blood loss | Comments |
Primary prophylaxis | Nonselective beta blocker* titrated to HR of 50 to 55 BPM or highest tolerated dose, eg:
Carvedilol starting at 3.25 mg orally twice daily (maximum 25 mg twice daily) is an alternative to nonselective beta blockers | N/A | Data supporting primary prophylaxis are lacking. We provide prophylaxis for the following patients:
|
Chronic bleeding | Nonselective beta blocker* titrated to HR of 50 to 55 BPM or highest tolerated dose, eg:
Carvedilol starting at 3.25 mg orally twice daily (maximum 25 mg twice daily) is an alternative to nonselective beta blockers | Iron repletion¶ Blood transfusion if hemoglobin <7 to 8 g/dLΔ | The nonselective beta blocker should be continued indefinitely |
Acute bleeding | Vasoactive medication, eg:
| Resuscitation with IV fluids and blood transfusion to maintain hemoglobin between 7 and 8 g/dL in patients with cirrhosis, or ≥8 g/dL in patients without cirrhosis | Patients with cirrhosis should also receive antibiotic prophylaxis for SBP for seven days¥, eg:
Once the acute bleeding episode is resolved, patients should be started on secondary prophylaxis with a nonselective beta blocker |
Refractory bleeding (chronic or acute) | Shunt therapy:
Liver transplantation Endoscopic treatment/APC if a focal lesion is present | As above | Patients with chronic bleeding who respond appropriately to iron repletion or transfusion may be managed expectantly |
Secondary prophylaxis | Nonselective beta blocker* titrated to HR of 50 to 55 BPM or highest tolerated dose, eg:
Carvedilol starting at 3.25 mg orally twice daily (maximum 25 mg twice daily) is an alternative to nonselective beta blockers | N/A | The nonselective beta blocker should be continued indefinitely |
HR: heart rate; BPM: beats per minute; N/A: not applicable; IV: intravenous; SBP: spontaneous bacterial peritonitis; DS: double strength (ie, trimethoprim 160 mg and sulfamethoxazole 800 mg per tablet); TIPS: transjugular intrahepatic portosystemic shunt; APC: argon plasma coagulation.
Antibiotic doses shown are for use in patients with normal renal function. Some agents require dose adjustment in patients with renal impairment.
* Provided there are no contraindications to beta blocker therapy. Patients who cannot take or do not tolerate nonselective beta blockers or carvedilol are treated like those with refractory bleeding.
¶ Refer to UpToDate topics on treatment of iron deficiency for details on methods for iron repletion.
Δ The decision to transfuse blood is complicated and depends on multiple different variables, including the presence of underlying unstable cardiac disease, the acuity and volume of bleeding, the presence of cirrhosis, and other variables. In those with cirrhosis, the target hemoglobin is typically 7 to 8 g/dL. Refer to UpToDate topics on the management of upper gastrointestinal bleeding for details.
◊ Not available in the United States.
§ In the United States, gastrointestinal bleeding is an off-label indication.
¥ Refer to UpToDate topics on the management of variceal hemorrhage for detailed discussions of antibiotic selection and administration.آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟