Distinctive aspects of peptic ulcer disease, Dieulafoy's lesion, and Mallory-Weiss syndrome in patients with advanced alcoholic liver disease or cirrhosis

Table 6 Special considerations in therapy for alcoholics with liver disease presenting with acute upper gastrointestinal bleeding

Recommended clinical practice	Rationale	Ref.
Consider early intubation for severe upper GI bleeding in a patient with alcoholism or alcoholic cirrhosis	These patients are at higher risk of aspiration because variceal bleeding related to alcoholism or cirrhosis is frequently massive, arises from the esophagus which is much closer to the trachea than other types of gastroduodenal bleeding; and the patient may be obtunded from hepatic encephalopathy from cirrhosis	Herrera[109], Rudolph et al[110]
Avoid sedatives and narcotics in patients with advanced liver disease	May precipitate hepatic encephalopathy from cirrhosis	Bamji et al[120], Prabhakar et al[121]
Monitor for hepatic encephalopathy	Patients with advanced cirrhosis at risk for hepatic encephalopathy	Rahimi et al[122]
Monitor for delirium tremens	Acute alcoholic withdrawal in hospital can induce delirium tremens	Ferguson et al[123], Holloway et al[124]
Avoid over-transfusion (maintain hemoglobin level at about 8 gm/dL)	Over-transfusion may exacerbate variceal bleeding by increasing portal hypertension	Herrera[109]
Patients often have thrombocytopenia which may contribute to the bleeding	Thrombocytopenia due to splenic sequestration from splenomegaly from portal hypertension and from direct alcohol toxicity to bone marrow	Pradella et al[125]
Patients often have a prolonged INR which may contribute to the bleeding	INR prolonged due to inadequate synthesis of liver-dependent clotting factors, such as factor V, due to advanced liver disease	Lata et al[126]
Administer thiamine	Prevent Wernicke’s syndrome from thiamine deficiency which is common in alcoholics	Hack et al[127]
Monitor for electrolyte abnormalities which may be more prominent in alcoholics		Knochel[117]
Consider early (urgent) esophagogastroduodenoscopy	Important to distinguish esophageal variceal bleeding from other etiologies of upper GI bleeding because esophageal variceal bleeding has different therapies	Buccino et al[37], del Olmo et al[38]
Consider empiric octreotide therapy before endoscopy	Alcoholics or patients with cirrhosis frequently have GI bleeding from esophageal varices which can be treated by octreotide therapy	Ludwig et al[128]
Perform paracentesis, as necessary, to exclude spontaneous bacterial peritonitis	Patients with cirrhosis and ascites are at high risk to develop spontaneous bacterial peritonitis due to mild immunosuppression with cirrhosis	Goulis et al[119]
Administer antibiotics in the presence of acute GI bleeding in a cirrhotic patient	Empiric antibiotic therapy lowers mortality because of decreased sepsis	Bernard et al[118]
Monitor BUN and creatinine levels to detect early hepatorenal syndrome. Avoid nephrotoxic medications such as NSAIDs	At high risk for renal deterioration due to decreased renal perfusion associated with cirrhosis and hypovolemia from GI hemorrhage	Ginès et al[129]
Exclude acute portal vein thrombosis in patients who suddenly develop severe esophageal varices by abdominal imaging studies (e.g., Doppler ultrasound or CT angiography)	Portal vein thrombosis in a patient with preexistent cirrhosis may exacerbate the portal hypertension and cause acute variceal bleeding	D’Amico et al[25]

GI: Gastrointestinal; INR: International normalized ratio; BUN: Blood urea nitrogen; NSAIDs: Nonsteroidal anti-inflammatory drugs.