Gastrointestinal endoscopy in the cirrhotic patient

Abstract

As advances in liver disease continue, including the increasing use of liver transplantation, the endoscopist needs to be familiar with the standards of care and potential complications in the management of the cirrhotic population. This includes both elective endoscopic procedures, such as screening colonoscopies and variceal banding, as well as the acutely bleeding cirrhotic patient. Peri-procedural management and standards of care for acute gastrointestinal hemorrhaging of cirrhotic patients will be emphasized. This article will focus on the plethora of data available to highlight the benefits of endoscopic intervention in the care of patients with liver disease and outline the areas of future emphasis.

Keywords:

• cirrhosis
• emergent endoscopy
• endoscopy
• liver disease
• portal hypertension
• routine endoscopy
• variceal bleeding

Financial & competing interests disclosure

HE Vargas has affiliations with the ABIM Transplant Hepatology Exam Committee and the TARGET HCV consortium. HE Vargas receives clinical research support from Gilead, BMS, Merck and AbbVie. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Paracentesis is not routinely recommended prior to elective colonoscopy in the cirrhotic population.

• Routine use of antibiotics for spontaneous bacterial peritonitis prophylaxis prior to elective endoscopy is not recommended.

• Propofol is a safe and effective medication for sedation in patients with cirrhosis, for both emergent and elective endoscopy.

• In cirrhotic patients with suspected upper gastrointestinal (GI) bleeding, routine intubation has not been shown to improve outcomes.

• There are no formal guidelines for transfusion, and transfusion should not be routinely done for elective endoscopy.

• With regards to red blood cell transfusion, a restrictive protocol should be utilized to avoid increasing portal pressure.

• In cirrhotic patients with GI bleeding, prophylactic administration of antibiotics is recommended.

• Adjuvant vasoactive therapy should be initiated when GI bleeding is suspected in a patient with cirrhosis.

• Timely endoscopic evaluation and hemostasis is imperative in the management of cirrhotic patients with GI bleeding.

• Endoscopic variceal band ligation is superior to sclerotherapy in the treatment of esophageal varices.

• Transjugular intrahepatic portosystemic shunt placement is currently preferred for refractory bleeding and likely increases survival in high-risk cirrhotic patients when placed early.