Acute variceal haemorrhage — Rapid

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.
Terlipressin should begin when variceal bleeding is suspected, before endoscopic proof, unless a product-specific contraindication makes risk unacceptable.
Prophylactic antibiotics are part of haemostasis because bacterial infection increases failure, rebleeding and mortality in cirrhosis.
Endoscopic variceal band ligation is first-line control for oesophageal varices; gastric fundal varices need a glue, radiological or shunt pathway.
INR in cirrhosis does not measure the whole rebalanced haemostatic system, and routine plasma normalisation adds volume without reliable benefit.
Balloon tamponade or a dedicated self-expanding oesophageal stent is a short bridge for uncontrolled oesophageal bleeding, never destination therapy.
Early or pre-emptive TIPS benefits selected high-risk patients, but the current BSG position adds UK caveats and requires rapid multidisciplinary selection.
After control, secondary prevention generally combines a tolerated non-selective beta-blocker with repeat banding and a complete liver-transplant and aetiology review.

Key red flags

Major portal bleed

Large fresh haematemesis, melaena, syncope, cool peripheries, oliguria or confusion occurs in a person with cirrhosis, splenomegaly or known varices.

Threatened airway

Repeated blood-filled vomiting, reduced consciousness, agitation, severe encephalopathy or hypoxia makes aspiration prevention and anaesthetic control an immediate priority.

Occult compensated shock

Tachycardia, narrow pulse pressure, delayed capillary refill or rising lactate can precede hypotension and a fall in measured haemoglobin.

Gastric variceal source

Endoscopy shows fundal or cardiofundal varices with active bleeding, requiring anatomy-directed glue, radiological obliteration or TIPS expertise rather than routine oesophageal bands.

Early haemostatic failure

Continued haematemesis, persistent transfusion need, shock or recurrent bleeding shortly after treatment prompts rescue escalation and portal decompression review.

Terlipressin adverse effect

Chest or abdominal pain, bradycardia, hypoxia, pulmonary oedema, cyanosis, skin change or hyponatraemia suggests clinically important vasoconstrictive toxicity.

Investigation priorities

Continuous ABC and perfusion observationsFirst step

Identify airway threat, haemorrhagic shock and response to resuscitation.

Management branches

First hourRun resuscitation and variceal treatment together

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.
Give monitored terlipressin and the local prophylactic antibacterial regimen immediately after checking key contraindications, without waiting for endoscopy.
Arrange urgent endoscopy after initial stabilisation and use anaesthetic airway protection when active bleeding or encephalopathy makes the procedure unsafe.

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.Monitor blood pressure, ECG or heart rate, oxygen saturation, sodium, potassium and fluid balance. The product is contraindicated in pregnancy and needs particular caution with cardiac or pulmonary disease, hypertension, low-output septic shock, QT risk and any myocardial, mesenteric, limb or skin ischaemia.

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.Obtain cultures when clinically indicated without delaying the first dose. Review renal, QT and Clostridioides difficile risks and narrow or redirect therapy when a source or organism is identified.

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