Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
Oesophageal varices
Gastroenterology and hepatology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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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.
Resuscitation targets perfusion and oxygen delivery while avoiding unnecessary volume or red-cell excess that can raise portal pressure and promote rebleeding.
Give terlipressin at presentation for suspected variceal bleeding unless contraindicated, with blood pressure, cardiac rhythm, oxygen, electrolytes and fluid monitoring.
Give prophylactic antibacterial therapy at presentation because bacterial infection and rebleeding risk are linked in cirrhosis.
Endoscopic band ligation is first-line definitive haemostasis for bleeding oesophageal varices; gastric or ectopic varices require a different expert pathway.
If banding fails, early specialist portal-decompression planning is essential; balloon tamponade is a temporary bridge with major aspiration and tissue-injury risks.
After survival, combined non-selective beta-blockade and repeat banding is commonly used for secondary prophylaxis, subject to haemodynamics and specialist review.
Primary prevention recommendations are evolving: use current NICE, BSG/BASL position statements and local hepatology policy rather than relying on an old isolated threshold.
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.
Airway-threatened bleed
Ongoing vomiting of blood, agitation, severe encephalopathy, reduced consciousness or hypoxia predicts aspiration and requires early anaesthetic-led airway planning.
Septic decompensation
Fever, confusion, hypotension, kidney injury or rising lactate may represent infection alongside bleeding and increases mortality, supporting immediate prophylactic antibiotics and infection assessment.
Early rebleeding
Renewed haematemesis, melaena with haemodynamic change, falling haemoglobin or increasing transfusion need after banding suggests haemostatic failure and prompts rescue escalation.
Terlipressin toxicity
New chest or abdominal pain, pallor or cyanosis, bradyarrhythmia, hypoxia, pulmonary congestion, hyponatraemia or reduced peripheral perfusion requires urgent medicine review.
Investigation priorities
01
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.
Administer terlipressin and prophylactic antibacterial therapy immediately under NICE and the local cirrhosis bundle, after checking contraindications and beginning required monitoring.
Arrange urgent therapeutic endoscopy once initial stabilisation and airway planning are adequate, without waiting for correction of an isolated cirrhotic INR.
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.Use under specialist monitoring of blood pressure, ECG or heart rate, oxygen saturation, sodium, potassium and fluid balance. It is contraindicated in pregnancy in this SmPC; review cardiovascular or pulmonary disease, hypertension, low-output septic shock, ischaemia, bradycardia, QT-prolonging medicines and skin necrosis risk.
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.Take cultures when clinically indicated but do not delay the first dose in an unstable bleed. Review Clostridioides difficile risk, QT or renal effects and narrow to culture results; persistent sepsis requires a source search rather than prolonged blind prophylaxis.
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.