Synopsis
Resuscitate acute portal hypertensive bleeding, start vasoactive and antibacterial treatment immediately and secure endoscopic or radiological haemostasis with secondary prevention.
- Haematemesis or melaena in cirrhosis is managed as portal hypertensive bleeding until endoscopy identifies a different lesion.
- Resuscitation restores perfusion while avoiding excessive crystalloid and red-cell replacement that can raise portal pressure and provoke further haemorrhage.
- A normal first haemoglobin does not exclude major acute loss because plasma equilibration has not yet occurred.
Key red flags
Large fresh haematemesis, melaena, syncope, cool peripheries, oliguria or confusion occurs in a person with cirrhosis, splenomegaly or known varices.
Investigation priorities
Identify airway threat, haemorrhagic shock and response to resuscitation.
Management branches
A patient with possible portal hypertension has significant haematemesis or melaena.
- Call senior gastroenterology, anaesthesia and critical care, assess airway and circulation, obtain large-bore IV access and activate major haemorrhage support when indicated.
- Send crossmatch, blood count, coagulation, fibrinogen, renal, liver, lactate and cultures and resuscitate to organ perfusion with individually targeted blood products.
Key medicines
Terlipressin acetate, GlypressinAdult Glypressin regimen: give 2 mg intravenously every 4 hours at first. From the second dose, reduce each dose to 1 mg when body weight is under 50 kg or adverse effects develop. Continue only until haemostasis has been maintained for 24 hours and never beyond the current 48-hour SmPC maximum. NICE's instruction to stop after definitive haemostasis or by day 5 is an outer pathway limit, not permission to exceed the shorter product licence.
Prophylactic antibacterial treatmentGive the locally recommended intravenous agent at presentation and define the short course using allergy, renal function, previous cultures, community or hospital acquisition and current antimicrobial resistance.