Variceal Haemorrhage

Key points

• Acute variceal bleeding: resuscitate first (ABC, two wide-bore cannulae) · transfuse red cells using a restrictive threshold and avoid over-transfusion, which raises portal pressure and can worsen bleeding.
• Do NOT give fresh frozen plasma routinely to "correct clotting" — offer it only if fibrinogen is < 1 g/l or INR/APTT is > 1.5× normal · platelets only if actively bleeding with platelets < 50 × 10⁹/l · prothrombin complex concentrate if on warfarin and actively bleeding.
• Give TERLIPRESSIN at presentation, before endoscopy, and continue until haemostasis is achieved or for up to 5 days · it is the only licensed vasoactive agent in the UK and has a mortality benefit.
• Give prophylactic broad-spectrum ANTIBIOTICS to anyone with cirrhosis and upper GI bleeding — this independently reduces mortality.
• Endoscopic band ligation is superior to sclerotherapy for oesophageal varices · gastric varices are treated with endoscopic injection of N-butyl-2-cyanoacrylate · balloon tamponade (Sengstaken-Blakemore) is a temporising bridge only · consider TIPS if bleeding is uncontrolled or recurs.
• Secondary prophylaxis: a non-selective beta-blocker (propranolol, or carvedilol) AND repeat band ligation at 2-4 week intervals until the varices are eradicated · consider TIPS if prophylaxis fails.

Decision points in this pathway

• Haemorrhage controlled?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.