UPPER GASTROINTESTINAL BLEEDING IN PATIENTS WITH CIRRHOSIS: BEYOND VARICEAL BLEEDING

Aims We aimed to investigate reasons for acute upper gastrointestinal bleeding(AUGIB) as well as to compare predictors and outcomes between portal(PH) and non-portal hypertension(NPH) related AUGIB in patients with cirrhosis.

Methods All cirrhosis patients presenting with AUGIB during a 7-year period(2012-2019) in a European tertiary care centre were retrospectively enrolled. Demographic, clinical, laboratory, and endoscopy data were retrieved from medical records.

Results A total of 357 cirrhotic patients were hospitalised during the study period. Overall, 56(16%) patients experienced 66 AUGIB episodes (25% female; alcoholic cirrhosis 57%; Child class A/B/C: 21%/60%/15%). The recorded AUGIB was the first bleeding episode in 62%, the majority presenting with melena(70%). In all, 44 episodes were related to PH, 12 to NPH, and 4 to both. Ιn 7 episodes no AUGIB source was identified. Six-week survival following AUGIB was dismal for Child C vs. other Child classes(log-rank test p=0.049) and when rebleeding occurred vs. no-rebleeding (log-rank test p=0.021). Survival following PH-AUGIB vs. NPH-AUGIB did not differ significantly(p>0.05). The recored AUGIB episode was the reason of initial decompensation for 9 patients with PH (20%) and 2 with NPH-AUGIB(16%, p>0.05). Among PH-AUGIB patients, band ligation was performed in 68%, histoacryl injection (fundic varices) in 14%, and no endotherapy in 18%. Among NPH-AUGIB patients, 17% were treated with adrenaline injection and hemoclips, 8% with adrenaline only; in 75% no endotherapy was undertaken. Rebleeding occurred in 7% in the PH vs. 0% in the NPH group (p>0.05). Rescue therapy with TIPS vs. interventional radiology/surgery was done in 2% vs. 0% respectively (p>0.05).

Conclusions PH related bleeding is the most common cause of AUGIB in cirrhotics with varices being the dominant source. About one-fifth of cirrhotics bleed from non-PH sources (mainly peptic ulcer disease) which may be their first decompensating event. Patient outcome is similar in PH and non-PH bleeding.