Upper gastrointestinal bleeding.
The current European-wide mortality rate from upper gastrointestinal bleeding has decreased from 42% in 198 to 14% in 2000. mortality from upper gastrointestinal bleeding in cirrhosis with CHILD A or B is close to 0. CHILD class C still exceeds 30%. The primary disposition includes fluid augmentation, blood transfusion, vasoactive drug therapy, antibiotic prophylaxis, and diagnosis or treatment by endoscopy should be completed within 6-12 hours if possible. The details are as follows.
1, body circulation support therapy: mean arterial pressure > 65 mmhg. to maintain tissue perfusion.
2, nasogastric tube: facilitate gastric emptying, improve the quality of endoscopic treatment, and theoretically reduce the occurrence of hepatic encephalopathy.
3, drug therapy: the current first-line drugs are mainly growth inhibitors and terlipressin, which can significantly improve the short-term bleeding control rate. Terlipressin is significantly better than placebo in a placebo-controlled RCT, but is contraindicated in patients with combined cardiovascular disease. Growth inhibitors are safe to use, but do not reduce mortality.
4. antibiotic prophylaxis: antibiotic prophylaxis reduced the rate of bacterial infection and improved short-term survival. 4-generation cephalosporins (RR 0.16; 95% CI 0.05C0.48) were superior to quinolones (RR 0.27; 95% CI 0.18C0.39).
5. Stopping hepatic encephalopathy: lactulose vs. control (14% vs. 40%,)
6, Endoscopic treatment: endoscopic treatment (ligatures and sclerotherapy) as soon as possible within 6-12 hours with ICU support. Transoral intubation is required to protect the airway in case of massive bleeding. Propofol is recommended for sedation. Cyanoacrylic acid is the 1st line agent for sclerotherapy.
7. TIPS: Early prophylactic treatment is available. It can also be used as salvage treatment for other hemostatic failures, with a 90% bleeding control rate and a 1-year survival rate of 52%. A recent RCT showed that for patients with active bleeding in CHILD C 10-13 or B, TIPS vs. drug and endoscopic therapy within 48 h. TIPS resulted in a significant reduction in mortality and treatment failure at 1 year, without a significant increase in the incidence of hepatic encephalopathy.
8.Triple-lumen, two-cystic tube: used with the intention of endoscopic treatment, TIPS, or before surgical procedures. Note that the airway must be protected by translaryngeal intubation.
9.Rehemorrhage prevention: Tipsan, TIPS, antibiotic prophylaxis.
Severe infection or infectious shock disposition.
Early treatment goals: mean arterial pressure ≥65mmHg, central venous pressure 8 and12mmHg, central venous oxygen saturation ≥70% and urine volume ≥0.5 ml?kg?1?h?1.
1.Early diagnosis and antibiotic treatment: Early diagnosis and treatment of infection is more important in cirrhotic patients than in the general population.
2.Circulatory support: as before.
3, hormone: early studies suggested that 50mg/6h cortisone shock was effective, recent RCTs have shown that hormone therapy does not benefit the survival rate of patients with cirrhosis co-infection, but increases the risk of infection. Patients with cirrhosis are often combined with inadequate hormone secretion, and a multicenter study of hormone use in patients who do not respond to ACTH is underway.
4. Other treatments: Ventilator support of low tidal volume (6 ml/kg of ideal body weight) and end-inspiratory pressure control (<30 cmH2O) is the gold standard for ARDS, but has not been studied in ARDS in cirrhosis. Sedation: use of short half-life drugs, e.g., propofol. CRRT: as in the general population, there is no standard in cirrhotic patients with severe co-infections. Glycemic control: strict glycemic control is not recommended. Recommended (144C180 mg/dl). Blood product use: same as general transfusion guidelines. Peptic ulcer prevention: H2 antagonists and proton pump inhibitors use.
Management of HRS.
1. Distinguish whether it is HRS or combined acute renal failure.
2. 30% of HRS is induced by SBP or other infections, so antibiotics should be given early if infection is suspected.
3. Albumin (1 g/kg for initial treatment and 20C40 g/day thereafter) in combination with terlipressin is the first-line treatment for type 1 HRS. Randomized or non-randomized studies have shown that terlipressin is effective in 50% of type 1 HRS. Other vasoactive drugs such as norepinephrine have also been used but data are scarce.
4. TIPS may improve renal function in HRS. However, surgery is contraindicated in liver failure.
5.Extracorporeal support systems such as MARS and Prometheus may be effective for type 1 HRS.
6.Liver transplantation: the optimal choice.
Hepatic encephalopathy.
Although data from studies of non-absorbable disaccharides are not superior to placebo, non-absorbable disaccharides (lactulose, lactitol) are currently the primary treatment for hepatic encephalopathy, with the therapeutic goal of maintaining 2-3 soft stools per day without diarrhea. Rifaximin (1100 or 1200 mg/d) is recommended to control the intestinal flora. Strictly controlled protein diet is not recommended. Normal protein intake is beneficial and safe for patients with cirrhosis combined with hepatic encephalopathy.
Stage 3-4 hepatic encephalopathy requires tracheal intubation and ICU management, and albumin dialysis may improve hepatic encephalopathy.
Mennosine-ornithine is not recommended because of conflicting findings.
Flumazenil (1 mg IV) is used for benzodiazepine-induced hepatic encephalopathy.