Thread by @LizzieAbyMD

@ScopingSundays @HassaanZiaMD @AtoosaRabiee @BilalMohammadMD @vaibhav_manu @AhmadBazarbashi @rmulkimd @RobertoSimonsMD @DrMalSimons @KellyHathornMD @NnekaUfereMD @JacquelineChuMD @TedWJamesMD 57 y/o M w/cirrhosis p/w melenic stools & hematemesis. EGD 1 yr ago w/small EV. BP 90/50, HR 110 & 96% on RA. Clammy extremities. Abdomen non tender. No ascites or edema. Pt has another episode of hematemesis. Hgb 8, Plt 165k, INR 1.8, Tb 2.1, Cr 1.4 & Na 134.
What is your plan?

@ScopingSundays @HassaanZiaMD @AtoosaRabiee @BilalMohammadMD @vaibhav_manu @AhmadBazarbashi @rmulkimd @RobertoSimonsMD @DrMalSimons @KellyHathornMD @NnekaUfereMD @JacquelineChuMD @TedWJamesMD To start out #ScopingSundays - we will quickly review the pre-endoscopic management of bleeding esophageal varices!
#livertwitter #GITwitter #tweetorial

@ScopingSundays @HassaanZiaMD @AtoosaRabiee @BilalMohammadMD @vaibhav_manu @AhmadBazarbashi @rmulkimd @RobertoSimonsMD @DrMalSimons @KellyHathornMD @NnekaUfereMD @JacquelineChuMD @TedWJamesMD When thinking about how to approach variceal bleed, consider this mnemonic -

Vasoconstrictor therapy
Antibiotics
Resuscitation
ICU level care
Endoscopy
ALternative/Rescue therapies
Beta blockade

Goals of therapy:
1 control bleeding
2 prevent early recurrence
3 prevent 6-wk 💀

@ScopingSundays @HassaanZiaMD @AtoosaRabiee @BilalMohammadMD @vaibhav_manu @AhmadBazarbashi @rmulkimd @RobertoSimonsMD @DrMalSimons @KellyHathornMD @NnekaUfereMD @JacquelineChuMD @TedWJamesMD Vasoactive agent:
Octreotide 50mcg IV bolus then 50mcg/H infusion x 2-5 days
Meta-analysis of 30 RCTs - the use of a vasoactive agent in acute variceal bleeding was associated w/ lower 7-day all-cause mortality & lower transfusion requirements
pubmed.ncbi.nlm.nih.gov/22486630/

@ScopingSundays @HassaanZiaMD @AtoosaRabiee @BilalMohammadMD @vaibhav_manu @AhmadBazarbashi @rmulkimd @RobertoSimonsMD @DrMalSimons @KellyHathornMD @NnekaUfereMD @JacquelineChuMD @TedWJamesMD Antibiotic prophylaxis in the setting of GIB leads to decreased:

@ScopingSundays @HassaanZiaMD @AtoosaRabiee @BilalMohammadMD @vaibhav_manu @AhmadBazarbashi @rmulkimd @RobertoSimonsMD @DrMalSimons @KellyHathornMD @NnekaUfereMD @JacquelineChuMD @TedWJamesMD Antibiotic ppx: Ceftriaxone 1g IV qd x 5-7 days
- Cirrhotics presenting w/GIB are at ⬆️risk of developing bacterial infections. Infections are assoc w/poor outcomes
- Antibiotic prophylaxis (in RCTs): leads to a⬇️in infections, recurrent bleeding & death
pubmed.ncbi.nlm.nih.gov/21707680/

@ScopingSundays @HassaanZiaMD @AtoosaRabiee @BilalMohammadMD @vaibhav_manu @AhmadBazarbashi @rmulkimd @RobertoSimonsMD @DrMalSimons @KellyHathornMD @NnekaUfereMD @JacquelineChuMD @TedWJamesMD Resuscitation
⭐️Volume resuscitation is critical
⭐️Transfusion goal Hb >7g/d
-Subgroup of patients with cirrhosis (CTP A/B) in the restrictive group vs. liberal (Hb>9) had significantly ⬇️early re-bleeding & mortality rates
-Over transfusion associated w/⬆️risk of AEs (MI & TACO)

@ScopingSundays @HassaanZiaMD @AtoosaRabiee @BilalMohammadMD @vaibhav_manu @AhmadBazarbashi @rmulkimd @RobertoSimonsMD @DrMalSimons @KellyHathornMD @NnekaUfereMD @JacquelineChuMD @TedWJamesMD Endoscopy:
⭐️Should be done ASAP, within 12 hours of admission once patient is HDS
See data by Chen et al. Journal of Hepatology 2012👇🏻 doi.org/10.1016/j.jhep…
▪️Consider this EASL algorithm for management of GI bleeding in the setting of portal HTN👇🏻
easl.eu/wp-content/upl…

@ScopingSundays @HassaanZiaMD @AtoosaRabiee @BilalMohammadMD @vaibhav_manu @AhmadBazarbashi @rmulkimd @RobertoSimonsMD @DrMalSimons @KellyHathornMD @NnekaUfereMD @JacquelineChuMD @TedWJamesMD Other considerations:
-INR is🚫a reliable indicator of coagulation status; routine use of FFP is 🚫recommended
-Transfuse for plt < 50
-Consider imaging studies to rule out HCC & PVT, which can further increase portal pressure & lead to VH & could modify the therapeutic strategy