Critical Care Management of Gastrointestinal Bleeding and Ascites in Liver Failure

Gastrointestinal (GI) bleeding and ascites are two significant clinical events that frequently present in critically ill patients with chronic liver failure or decompensated cirrhosis. GI bleeding in patients with cirrhosis, particularly portal hypertensive-associated bleeding, carries a high short-term mortality (15-25%) and requires early initiation of a vasoactive agent and antibiotics as well as timely endoscopic management. Conservative transfusion strategies and adequate airway protection are also imperative to assist in bleeding control. The presence of ascites among hospitalized cirrhotics requires early analysis of ascitic fluid to diagnose spontaneous bacterial peritonitis and initiate appropriate antibiotics and albumin to reduce patients' high associated mortality rates of greater than 25%. Appropriate utilization of portal decompression using transjugular intrahepatic portosystemic shunt placement for selected patients with failure to control bleeding or ascites and early consideration for liver transplantation referral is critical to improve patient survival. This review will aim to elucidate the current strategies for the management of critically ill patients with chronic liver failure presenting with GI bleeding or ascites.