Acute Variceal Hemorrhage Management (Baveno VII 2022)

Algorithm Steps

1. ▶

   Start

   Acute Variceal Hemorrhage

   Suspected or confirmed variceal bleeding

   1. ⚠

      Warning

      Initial Resuscitation

      SIMULTANEOUS interventions

      • Secure airway (intubate if altered MS/massive)
      • Large bore IV access x 2
      • Type and crossmatch
      • Restrictive transfusion: Target Hgb 7-8 g/dL
      • Avoid over-resuscitation (worsens PHT)
      • Correct coagulopathy if INR >2.5
      • Platelets if <50,000
      1. ●

         Action

         Vasoactive Therapy (START IMMEDIATELY)

         Before EGD - reduces portal pressure

         • OCTREOTIDE (US first-line):
         • - Bolus: 50 mcg IV
         • - Infusion: 50 mcg/hr x 2-5 days
         • TERLIPRESSIN (if available):
         • - 2 mg IV q4h x 48h, then 1 mg q4h
         • - Contraindicated in CAD, PVD
         • OR SOMATOSTATIN:
         • - Bolus: 250 mcg IV
         • - Infusion: 250-500 mcg/hr
         1. ●

            Action

            Prophylactic Antibiotics

            Reduces mortality - START IMMEDIATELY

            • CEFTRIAXONE 1g IV q24h (preferred)
            • - For 5-7 days
            • - Reduces rebleeding and mortality
            • - Prevents SBP
            • ALTERNATIVE: Norfloxacin 400mg PO BID
            • (if low-risk, no quinolone resistance)
            1. ●

               Action

               PPI Therapy

               After banding

               • High-dose PPI after EVL
               • Pantoprazole 40mg IV BID or
               • Omeprazole 40mg IV BID
               • Promotes ulcer healing post-banding
               1. ●

                  Action

                  Urgent EGD

                  Within 12 hours of presentation

                  • Timing: Within 12 hours
                  • After hemodynamic stabilization
                  • Intubation if: Massive bleed, encephalopathy
                  • Erythromycin 250mg IV 30-90 min before
                  • (improves visualization)
                  1. ◆

                     Decision

                     Endoscopic Findings

                     Type of varices

                     1. ●

                        Action

                        Esophageal Varices

                        Band ligation first-line

                        • ENDOSCOPIC VARICEAL LIGATION (EVL)
                        • - First-line therapy
                        • - Multiple bands at bleeding site
                        • - Start distally, move proximally
                        • SCLEROTHERAPY:
                        • - If EVL not possible
                        • - Higher complication rate
                        1. ◆

                           Decision

                           Hemostasis Achieved?

                           Assess for rebleeding

                           1. ⚠

                              Warning

                              Rescue Therapy

                              For refractory bleeding

                              • BALLOON TAMPONADE (bridge to TIPS):
                              • - Sengstaken-Blakemore or Minnesota tube
                              • - Inflate gastric balloon first
                              • - Max 24 hours
                              • - Intubate before placement
                              • SELF-EXPANDING METAL STENT:
                              • - Danis/SX-Ella stent
                              • - Alternative to balloon
                              • Then → TIPS
                              1. ●

                                 Action

                                 TIPS (Transjugular Intrahepatic Portosystemic Shunt)

                                 For refractory/high-risk

                                 • INDICATIONS:
                                 • - Refractory to endoscopic therapy
                                 • - High-risk patients (preemptive TIPS)
                                 • EARLY/PREEMPTIVE TIPS:
                                 • - Within 72h (ideally <24h)
                                 • - For Child-Pugh B with active bleeding
                                 • - For Child-Pugh C (10-13 points)
                                 • COVERED STENTS preferred
                                 • Reduces rebleeding to <15%
                                 1. ●

                                    Action

                                    Secondary Prophylaxis

                                    Prevent rebleeding

                                    • NSBB + EVL combination:
                                    • - Propranolol: Target HR 55-60
                                    • - Or Carvedilol 6.25-12.5mg BID
                                    • - Repeat EVL q2-4 weeks until obliterated
                                    • If TIPS placed: Annual surveillance
                                    • Lifelong therapy required
                                    1. ✓

                                       Outcome

                                       Outcomes

                                       Prognosis

                                       • 6-week mortality: 15-20%
                                       • Rebleeding without prophylaxis: 60%
                                       • Rebleeding with NSBB + EVL: 20-30%
                                       • TIPS controls bleeding: >90%
                                       • Consider transplant evaluation
                     2. ●

                        Action

                        Gastric Varices

                        Cyanoacrylate glue or TIPS

                        • GOV1 (extending from EV): EVL may work
                        • GOV2/IGV1: Cyanoacrylate injection
                        • - 0.5-1 mL per injection
                        • - Mixed with lipiodol
                        • Consider early TIPS for gastric varices