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Textbook/Gastroenterology and hepatology/Oesophageal varices/Rapid

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Oesophageal varices

Essential points for quick revision.

2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending

Escalate

Suspected variceal haemorrhage is a major upper-GI bleeding emergency. Call gastroenterology, anaesthesia and critical care early; protect the airway when massive haematemesis or impaired consciousness creates aspiration risk; obtain large-bore IV access and resuscitate without over-transfusion. NICE recommends terlipressin and prophylactic antibiotics at presentation, followed by urgent endoscopy after stabilisation and band ligation for oesophageal varices. Uncontrolled bleeding requires immediate rescue planning for balloon or dedicated oesophageal stent bridging and transjugular intrahepatic portosystemic shunt rather than repeated uncoordinated endoscopy.

Synopsis

Prevent first variceal haemorrhage where appropriate and deliver coordinated vasoactive, antimicrobial, endoscopic and portal-decompression care during acute bleeding.

Oesophageal varices are portosystemic collaterals caused by portal hypertension, most commonly from cirrhosis but also portal or splenic venous obstruction and other vascular disease.
Bleeding can be massive because elevated portal pressure, fragile variceal walls, infection and cirrhosis-associated haemostatic disturbance act together.
Haematemesis or melaena in a person with cirrhosis is treated as variceal until urgent endoscopy establishes another source.

Key red flags

Acute variceal haemorrhage

Large-volume fresh haematemesis, melaena, syncope or shock occurs in a person with cirrhosis, portal hypertension, prior varices or portal venous thrombosis.

Investigation priorities

Continuous haemodynamic and airway assessmentFirst step

Recognise shock, aspiration risk and response to blood support.

Management branches

At presentationDeliver the variceal bleed bundle in parallel

A person with known or possible portal hypertension presents with haematemesis or significant melaena.

Activate senior gastroenterology, anaesthetic and critical-care support, protect the airway where bleeding or consciousness requires it, and obtain large-bore IV access with continuous observation.
Send urgent bloods, group-and-screen and cultures, resuscitate to clinical perfusion and use restrictive, individualised red-cell support rather than routine over-transfusion.

Key medicines

Terlipressin acetate for acute variceal bleedingFor Glypressin 1 mg, give 2 mg by intravenous injection every 4 hours initially; after the initial dose reduce to 1 mg every 4 hours if body weight is below 50 kg or adverse effects occur. Continue until bleeding has been controlled for 24 hours, but for no longer than 48 hours. NICE advises stopping terlipressin after definitive haemostasis or by 5 days; this pathway ceiling does not permit a named product to exceed its shorter current SmPC maximum.

Prophylactic antibacterial therapyGive the locally recommended intravenous antibacterial at presentation, using the current cirrhosis or upper-GI bleed regimen and adjusting for allergy, kidney function, prior resistant organisms and local microbiology; define and review the short course.

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Sources and review status6 sources · checked 27 Aug 2026 · clinical review pending

Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

NICE CG141 acute upper gastrointestinal bleedingUK recommendations for terlipressin, prophylactic antibiotics, band ligation, rescue TIPS and endoscopy timing.
BSG variceal haemorrhage guideline and 2022 addendumEndorsed UK acute and secondary prophylaxis framework with an explicit caution that primary prophylaxis is evolving.
BSG and BASL decompensated cirrhosis admission care bundleCoordinated first-day management of bleeding, infection and organ decompensation.
NICE NG50 cirrhosis assessment and managementCurrent prevention, surveillance and non-selective beta-blocker recommendations for cirrhosis.
Glypressin 1 mg summary of product characteristicsCurrent licensed acute variceal dose, forty-eight-hour limit, contraindications and required monitoring.
BNF carvedilol monographUK dosing and safety information for specialist portal-hypertension prophylaxis.

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom