Gastrointestinal & Hepatic · Topic 2 of 26

Variceal Hemorrhage

Gastrointestinal · GI bleeding

Variceal Hemorrhage

Any patient with cirrhosis who bleeds gets octreotide and ceftriaxone now, blood only to hemoglobin about 7, and banding within 12 hours.

Key numbers

Octreotide 50 mcg bolus, then infusion50 mcg → 25–50 mcg/h

Ceftriaxone 1 g IV dailyCeftriaxone 1 g/24 h

Endoscopy with band ligation within 12 hoursEGD ≤ 12 h

Transfuse to hemoglobin about 7 onlyHgb ~7 g/dL

Preemptive TIPS within 72 hours if high riskTIPS ≤ 72 h

01 · DoStart vasoactive drug and IV antibiotic immediately

Every patient with known or suspected cirrhosis and acute GI bleeding gets a vasoactive drug (octreotide in the US) and an IV antibiotic as soon as possible — before endoscopy.

02 · FirstEndoscopy with band ligation within 12 hours

Perform upper endoscopy within 12 hours of presentation; if esophageal variceal bleeding is confirmed, treat with endoscopic band ligation.

03 · DoTransfuse to hemoglobin about 7 only

Restrict red cell transfusion to a target hemoglobin of about 7 g/dL, higher only for comorbidity such as ischemic coronary disease (8 g/dL per ACG) or instability; overtransfusion raises portal pressure and worsens survival.

Do right now

In this order

First moves

Intubate before endoscopy if mental status altered

→

Start vasoactive drug and IV antibiotic immediately

→

Transfuse to hemoglobin about 7 onlyHgb ~7 g/dL

→

Endoscopy with band ligation within 12 hoursEGD ≤ 12 h

→

Preemptive TIPS within 72 hours if high riskTIPS ≤ 72 h

Why each step

Intubate before endoscopy if mental status alteredAssess the airway first: intubate before endoscopy for altered mentation or aspiration risk, and extubate as soon as safe. Aspiration pneumonia is the most common infection; avoid routine pre-endoscopy NG tubes.

Start vasoactive drug and IV antibiotic immediatelyEvery patient with known or suspected cirrhosis and acute GI bleeding gets a vasoactive drug (octreotide in the US) and an IV antibiotic as soon as possible — before endoscopy.

Transfuse to hemoglobin about 7 onlyRestrict red cell transfusion to a target hemoglobin of about 7 g/dL, higher only for comorbidity such as ischemic coronary disease (8 g/dL per ACG) or instability; overtransfusion raises portal pressure and worsens survival.

Endoscopy with band ligation within 12 hoursPerform upper endoscopy within 12 hours of presentation; if esophageal variceal bleeding is confirmed, treat with endoscopic band ligation.

Preemptive TIPS within 72 hours if high riskRecommend preemptive TIPS within 72 hours (ideally 24) of endoscopy for Child-Pugh C 10–13, or Child-Pugh B above 7 with active bleeding at endoscopy, unless TIPS is absolutely contraindicated.

Management

Orders

Octreotide 50 mcg bolus, then infusion must knowOctreotide: 50 mcg IV bolus, then 25–50 mcg/h infusion, continued for 2–5 days once portal hypertensive bleeding is confirmed; it lowers portal pressure and collateral flow.

Ceftriaxone 1 g IV daily must knowGive ceftriaxone 1 g IV every 24 hours (tailored to local resistance and allergies) until discharge or 5 days, whichever is shorter; stop once bleeding is controlled if there is no active infection.

Uncontrolled bleeding: tamponade or stent, then TIPSIf bleeding is uncontrolled, place balloon tamponade (limit about 24 hours) or a covered esophageal stent as a bridge to salvage TIPS; rescue TIPS treats rebleeding despite vasoactive drugs and banding.

Secondary prophylaxis: beta-blocker plus bandingWithout TIPS, start a nonselective beta-blocker (propranolol, nadolol or carvedilol) when vasoactive therapy stops and repeat band ligation every 2–4 weeks until obliteration; rebleeding reaches 60% at 1 year without prophylaxis.

Primary prophylaxis: carvedilol preferredFor varices that have not bled, carvedilol (6.25–12.5 mg/day) is the preferred nonselective beta-blocker; band ligation is the alternative when beta-blockers are contraindicated or not tolerated.

Red flags & don'ts

Avoid harm

No FFP or platelets to correct numbers avoidDo not give fresh frozen plasma or platelets to reach INR or platelet targets: INR does not reflect hemostasis in cirrhosis, there is no benefit, and plasma may cause harm.

TIPS cautions: heart failure, pulmonary hypertension, encephalopathy avoidTIPS is relatively contraindicated with heart failure, moderate or severe pulmonary hypertension or hepatic encephalopathy, and mortality after TIPS rises with MELD above 18.

The rules

Know these

Stop the PPI once varices bledDiscontinue proton pump inhibitors once variceal bleeding is confirmed as the source unless another indication exists — they add infection risk in cirrhosis.

Variceal or nonvariceal upper bleed?

Commonly confused

Drugs before endoscopy	Octreotide plus IV ceftriaxone
Endoscopy timing	Within 12 hours
Endoscopic therapy	Band ligation
PPI after endoscopy	Stop once a variceal source is confirmed
Failure	Balloon tamponade or stent as bridge to TIPS

Commonly confused

Tell apart

Gastric fundal varices: glue, TIPS or BRTOBleeding cardiofundal gastric varices get the same initial care, then contrast cross-sectional imaging and cyanoacrylate injection, TIPS or BRTO; gastric varices from isolated splenic vein thrombosis need splenectomy, splenic vein stenting or embolization.

More detail

Reference

Show 5 reference facts

Six-week mortality after acute variceal hemorrhage is still 10–15%; most deaths occur in Child-Pugh C, and Child-Pugh A patients rarely die of variceal bleeding.

Alternatives where available: somatostatin 250 mcg bolus then 250–500 mcg/h, or terlipressin 2 mg IV every 4–6 hours for 24–48 hours then 1 mg every 4–6 hours (not approved for this use in North America).

Once stable, image the abdomen (contrast CT/MRI or Doppler ultrasound) for portal vein thrombosis and liver cancer; restart enteral feeding once bleeding is controlled — bands do not preclude a feeding tube.

Nonvariceal ulcer bleeding is managed differently: erythromycin (IV PPI optional) before endoscopy within 24 hours, thermal or clip hemostasis, high-dose PPI for 3 days, and embolization if endoscopic therapy fails.

Covered esophageal stents can stay in place up to about 1 week, compared with roughly 24 hours for balloon tamponade, with similar efficacy and better safety.

Pearl

Drugs before the scope: vasoactive therapy and antibiotics start the moment a patient with cirrhosis bleeds — not after endoscopy confirms varices.

Sources · Kaplan DE et al. AASLD Practice Guidance on risk stratification and management of portal hypertension and varices in cirrhosis. Hepatology 2024;79:1180–1211 · Laine L et al. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. Am J Gastroenterol 2021;116:899–917 · Merck Manual Professional — Cirrhosis (TIPS contraindications; updated 2026) · Gralnek IM et al. Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: ESGE Guideline. Endoscopy 2022;54:1094–1120 · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).