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The medical management of gastrointestinal bleeding in liver disease

The medical management of gastrointestinal haemorrhage in patients with liver disease can be divided into three sections: control of active bleeding; prevention of re-bleeding, and prevention of the initial haemorrhage. Although this review will deal mainly with bleeding from oesophageal varices, it should be remembered that approximately one-third of patients with portal hypertension bleed from gastric or duodenal ulcers which require treatment in the conventional manner. Surgery, although relatively contra-indicated in patients with liver disease, may be the only way to control haemorrhage in some patients, but will be mentioned only briefly in this article for the sake of completeness. The recent popularity of injection sclerotherapy for oesophageal varices has been accompanied by an increasing interest in endoscopic methods of treating non-variceal upper gastrointestinal haemorrhage with injection sclerotherapy, lasers and topically applied agents. This topic has been the subject of an excellent recent review' and will not be discussed further here. Gastrointestinal bleeding in patients with liver disease is one of the few indications for urgent endoscopy since the actual site of bleeding dictates the subsequent therapy. As endoscopic sclerotherapy for control of active bleeding becomes more widely practised, the requirement for urgent endoscopy is further justified. If endoscopy is delayed and carried out some time after the haemorrhage, secondary erosions may be present (D. Westaby personal communication) and erroneously presumed to be the cause of the bleeding. This may partly explain why bleeding, believed to be from gastric erosions, seems to behave in a similar fashion to variceal haemorrhage in apparently responding to propranolol therapy in patients with portal hypertension and large oesophageal varices.2