variceal bleeding
Contents
Acute variceal haemorrhage (AVH) has a 6-week mortality of 15–20%. Management is simultaneous: resuscitate (restrictive transfusion), vasoactive drugs (octreotide or terlipressin), antibiotics, and endoscopy within 12 hours. Primary prophylaxis with NSBB or endoscopic band ligation (EBL) prevents first bleeds; secondary prophylaxis combines both. Early TIPS (within 72 hours) improves survival in high-risk patients (Child-Pugh C 10–13 or Child-Pugh B with active bleeding at endoscopy).
primary prophylaxis
Start once varices are identified on screening OGD, or when CSPH is confirmed non-invasively (see cirrhosis).
who needs it
| finding | prophylaxis |
|---|---|
| no varices, no CSPH by Baveno VII | none — repeat LSM + platelets annually |
| small varices, no red signs, Child-Pugh A | NSBB preferred; surveillance OGD acceptable alternative |
| small varices + red wale signs or Child-Pugh B/C | NSBB |
| medium/large varices | NSBB or EBL |
non-selective beta-blockers
- Carvedilol 6.25–12.5 mg daily — preferred first-line in compensated disease; greater portal pressure reduction than propranolol via additional anti-α1 activity
- Propranolol 20–40 mg BID, titrate to max 320 mg/day (target resting HR 55–60 bpm)
- Nadolol 40 mg daily, titrate similarly
- MAP <65 mmHg or SBP <90 mmHg
- AKI or hepatorenal syndrome
- Refractory ascites with hypotension (the “window hypothesis” — NSBB may worsen haemodynamics in end-stage patients, though this remains debated)
- spontaneous bacterial peritonitis with haemodynamic compromise
Reassess after the acute episode resolves — NSBB can often be restarted.
endoscopic band ligation
EBL every 2–4 weeks until variceal eradication, then surveillance OGD at 3–6 months and annually. Equivalent to NSBB for primary prophylaxis of medium/large varices. Preferred over NSBB if intolerance or contraindication.
acute variceal haemorrhage
This is the 2am protocol. All steps happen simultaneously, not sequentially.
resuscitation
- Restrictive transfusion — target Hb 70 g/L (Villanueva, NEJM 2013). Liberal transfusion (Hb >90) increases portal pressure and rebleeding.
- Volume resuscitation with crystalloid — avoid over-resuscitation (raises portal pressure)
- Correct coagulopathy only if clinically significant bleeding — do not chase the INR; cirrhotic INR does not reflect bleeding risk. Platelet transfusion if <50 × 10⁹/L with active bleeding.
- Airway — intubate for GCS ≤8 or massive haematemesis before endoscopy
Tranexamic acid does not reduce mortality in GI bleeding and may increase VTE risk. The HALT-IT trial (2020) showed no benefit and a signal of harm from intestinal ischaemia. Do not use.
pharmacotherapy — start immediately
| agent | dose | notes |
|---|---|---|
| octreotide | 50 µg IV bolus → 50 µg/hr infusion × 3–5 days | most commonly used in Canada |
| terlipressin | 2 mg IV q4h × 48 h → 1 mg q4h | not marketed in Canada; international standard |
Start before endoscopy — vasoactive drugs reduce portal pressure and improve endoscopic conditions.
antibiotics — start immediately
Ceftriaxone 1 g IV daily × 5–7 days (preferred in advanced cirrhosis, quinolone-resistant settings). Alternative: norfloxacin 400 mg PO BID. Antibiotics reduce bacterial infections, rebleeding, and mortality — they are as important as vasoactive drugs.
endoscopy — within 12 hours
- EBL is the treatment of choice for oesophageal varices
- Erythromycin 250 mg IV 30–120 min before endoscopy improves gastric visualisation (prokinetic to clear blood)
- If bleeding is uncontrolled at endoscopy → balloon tamponade (Sengstaken-Blakemore or Minnesota tube) as bridge to TIPS; maximum 24 hours
early TIPS — within 72 hours
Preemptive TIPS with PTFE-covered stent for high-risk patients who survive initial resuscitation:
- Child-Pugh C 10–13 (regardless of endoscopic findings)
- Child-Pugh B with active bleeding at index endoscopy
García-Pagán, NEJM 2010 showed early TIPS reduced treatment failure and mortality compared to standard medical + endoscopic therapy in these groups. This is not rescue TIPS — it is a planned procedure within 72 hours (ideally <24 hours) of admission.
Heart failure (right-sided), MELD >30 (relative — very high procedural mortality), Child-Pugh >13, active sepsis, severe pulmonary hypertension. Post-TIPS hepatic encephalopathy occurs in ~25–35%; manage with lactulose ± rifaximin.
secondary prophylaxis
After surviving an episode of AVH, rebleeding risk without prophylaxis is ~60% at 1 year.
Combination therapy: NSBB + EBL
- NSBB (carvedilol, propranolol, or nadolol) started once haemodynamically stable (typically day 3–5)
- EBL repeated every 2–4 weeks until variceal eradication
- Combination is superior to either alone for secondary prophylaxis
TIPS if rebleeding despite combination therapy, or as the primary strategy if early TIPS criteria were met at index bleed.
gastric varices
- GOV1 (extending along lesser curve from oesophageal varices) — treat as oesophageal varices (EBL, NSBB)
- GOV2 / IGV1 (fundal varices) — EBL is ineffective; use cyanoacrylate glue injection or TIPS. BRTO (balloon-occluded retrograde transvenous obliteration) at specialist centres.
common traps
- Liberal transfusion — Hb target >90 g/L raises portal pressure and rebleeding risk. Restrictive (target 70 g/L) improves survival.
- Forgetting antibiotics — they reduce mortality independently of infection status. Ceftriaxone on arrival, not after culture results.
- Correcting the INR — cirrhotic INR does not predict bleeding. FFP raises volume and portal pressure without reducing bleeding risk.
- Missing the early TIPS window — high-risk patients (Child-Pugh C 10–13 or B with active bleeding) benefit from TIPS within 72 hours, not as rescue after rebleeding.
- Stopping NSBB permanently after an AKI — reassess once the acute illness resolves. Most patients can restart once MAP and renal function recover.
related: cirrhosis · decompensated cirrhosis · hepatorenal syndrome · spontaneous bacterial peritonitis · upper GI bleeding