Suspected variceal bleeding (adult)
Adult with known or suspected cirrhosis and haematemesis or melaena. Treat as variceal bleeding until endoscopy.
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GastroenterologyEmergency
Acute Variceal Bleeding in Cirrhosis (Baveno VIII)
Acute Variceal Bleeding in Cirrhosis (Baveno VIII): Suspected variceal bleeding (adult) → Resuscitate in ICU or HDU: restrictive transfusion, no FFP → A...
Pathway Overview
18 steps
Algorithm Steps
18 total
01Start 02Action Resuscitate in ICU or HDU: restrictive transfusion, no FFP
2 large-bore IV lines, crossmatch. Avoid over-transfusion (raises portal pressure). Anticoagulants (warfarin, DOAC, heparin): stop them; if unstable or severe bleeding, reverse (see below). Hold NSBB and antihypertensives while bleeding or hypotensive.
- Red cells: transfuse conservatively; target Hb 70-80 g/L. Individualise for heart disease, age and ongoing bleeding. Massive bleeding: activate the local massive transfusion protocol
- Warfarin with unstable or severe bleeding: IV vitamin K plus prothrombin complex concentrate (dose per local protocol). DOAC: consider a specific reversal agent or PCC. Heparin or LMWH: stop it; reversal per local protocol. Do not delay endoscopy
- Antiplatelets: stop aspirin given for primary prevention. Aspirin for secondary prevention: do not stop routinely. Dual therapy: hold the second agent, keep aspirin, ask cardiology
- Cirrhosis without warfarin: do not give FFP to correct the INR (INR does not show bleeding risk). No tranexamic acid, no recombinant factor VIIa. Platelets and fibrinogen: no set target; consider case by case only if bleeding is not controlled
03Warning Airway: intubate before endoscopy if altered consciousness or vomiting blood
Protect the airway before endoscopy in these patients.
- Extubate as soon as possible after endoscopy
- Nasogastric tube and airway manipulation: use caution (aspiration and chest infection risk)
04Warning Terlipressin cautions: if present, use octreotide
Check these before you choose terlipressin.
- Pregnancy: contraindicated. Unstable angina or recent MI: do not use
- Coronary, cerebral or peripheral vascular disease, arrhythmia, long QT, uncontrolled hypertension, severe asthma or COPD: strict monitoring or avoid
- New breathing difficulty, hypoxia or fluid overload: risk of respiratory failure
05Action Start a vasoactive drug now, before endoscopy
Give one drug as soon as variceal bleeding is suspected. Continue 2-5 days, or until TIPS is placed. After successful endoscopic haemostasis, a shorter course (even 24 h) is an option if an NSBB is then started. Terlipressin: at 48 h (Australian PI limit), if still needed, continue vasoactive therapy by the local rule (for example switch to octreotide).
- Octreotide (adult): 50 microgram IV bolus, then 50 microgram/h IV infusion. Monitor blood glucose
- OR terlipressin (adult, Australian labelling as terlipressin base): 1.7 mg IV every 4 h; 0.85 mg every 4 h once bleeding is controlled, if weight under 50 kg or adverse effects
- Australian PI: terlipressin course no more than 48 h in total; 1.7 mg base = 2 mg terlipressin acetate in overseas guidelines
- On terlipressin: monitor BP, ECG, SpO2, sodium, potassium and fluid balance
06Action Antibiotic prophylaxis from admission
All patients with cirrhosis and upper GI bleeding. Reduces infection and death.
- Ceftriaxone 1 g IV every 24 h (third-generation cephalosporin preferred)
- Allergy to any cephalosporin: do not give ceftriaxone. Previous severe penicillin or other beta-lactam reaction: higher risk. Use the local alternative
- Choose the agent by local resistance patterns and antimicrobial policy
- Stop 2-5 days after successful haemostasis. Child-Pugh A: a shorter course may be enough
07Action Supportive care: lactulose, nutrition, stop PPI
Prevent encephalopathy and infection. Start oral nutrition as soon as possible.
- Lactulose (oral or enema) to clear blood from the gut and prevent hepatic encephalopathy
- Alcohol-related liver disease: give IV thiamine before glucose and watch for alcohol withdrawal
- PPI started before endoscopy: stop after endoscopy unless there is another indication (e.g. peptic ulcer)
- When stable: contrast CT or MRI abdomen to exclude portal vein thrombosis and HCC and map collaterals
08Action Endoscopy within 12 h, after resuscitation
Unstable patient: as soon as it is safe. Experienced endoscopist available 24/7. Secure the airway first if needed.
- Erythromycin 250 mg IV 30-90 min before endoscopy, unless QT prolongation
09Decision Source of bleeding at endoscopy?
Oesophageal varices or GOV1; GOV2 or isolated gastric varices; or a non-variceal source
- Oesophageal or GOV1
10Action Oesophageal varices or GOV1: band ligation (EVL)
EVL is the first-line endoscopic therapy for oesophageal variceal bleeding.
- GOV1: EVL, with or without gastric varix injection
- Clips, haemostatic powder or fibrin glue are not first-line therapy
11Decision Bleeding controlled after endoscopic therapy?
Treatment failure: no control of bleeding, or rebleeding within 5 days
- If Yes
12Decision Controlled: pre-emptive TIPS criteria met?
Oesophageal or GOV1 bleeding with Child-Pugh C 10-13 points, or Child-Pugh B 8-9 with active bleeding at endoscopy, or HVPG 20 mmHg or more, or MELD 19 or more at first endoscopy (Australian TIPS recommendations 2026). GOV2 or IGV1: TIPS as soon as possible is preferred for all; answer Yes.
- If Yes
13Action High risk, or GOV2/IGV1: covered TIPS within 72 h (ideally under 24 h)
PTFE-covered stent. Reduces rebleeding and death. Transfer to a TIPS centre if not available on site.
- Contraindications: moderate-severe pulmonary hypertension, advanced heart failure, severe valve disease, uncontrolled sepsis
- Encephalopathy, ACLF, high bilirubin, high MELD or severe alcohol-related hepatitis are not absolute contraindications
- 72 h window missed: TIPS within 2 weeks (Child-Pugh C 10-13) or 1 week (Child-Pugh B with active bleeding) may still help
- GOV2 or IGV1 with TIPS contraindicated: transvenous obliteration (e.g. BRTO), endoscopic or surgical therapy (team decision)
- After TIPS: no NSBB or routine EVL needed
- Doppler of the shunt at 1 week, 3 months, then every 6 months
14Outcome Follow-up and transplant assessment
Decompensated cirrhosis: consider liver transplant referral. Treat the cause of liver disease and look for the bleeding precipitant. No TIPS yet and also ascites or encephalopathy: consider TIPS. Restart anticoagulation when bleeding is controlled, timed by the indication. Blood loss anaemia: consider iron.
If No15Action Not high risk: finish acute care, then NSBB plus EVL or gastric therapy
Secondary prophylaxis. Start the NSBB before discharge. No NSBB with asthma, sinus bradycardia or 2nd-3rd degree AV block: EVL alone. Hold it if systolic BP under 90 mmHg, MAP under 65 mmHg or HRS-AKI. GOV2 or IGV1 where TIPS is not possible: no EVL; NSBB (if no contraindication) plus transvenous obliteration or endoscopic therapy (hepatology decision).
- Complete the vasoactive drug and antibiotics (2-5 days)
- Carvedilol preferred: start 6.25 mg daily; target 12.5 mg a day (6.25 mg twice daily); up to 25 mg a day only with arterial hypertension
- Or propranolol: start 20-40 mg twice daily, adjust every 2-3 days to heart rate 55-60/min; target at least 40 mg twice daily. Maximum 160 mg twice daily; with ascites maximum 80 mg twice daily
- Oesophageal varices or GOV1: repeat EVL every 1-3 months until varices are eradicated, then surveillance endoscopy. Rebleeding despite NSBB plus EVL: TIPS
- Path rejoins step 14Shared downstream outcome
If No16Action Not controlled: bridge with stent or balloon, then salvage TIPS
Refractory bleeding. Correct haemostatic abnormalities case by case.
- Bridge: covered self-expanding metal stent preferred for oesophageal varices; otherwise balloon tamponade (airway protected first; remove within 24-48 h)
- Salvage PTFE-covered TIPS; if not available, transfer to a TIPS centre once stabilised
- Discuss salvage TIPS for every patient, whatever the age, Child-Pugh or MELD score. Child-Pugh 14 or more, or MELD over 30 with lactate over 12 mmol/L: TIPS may be futile unless early liver transplant is planned; decide case by case
- TIPS contraindications: moderate-severe pulmonary hypertension, advanced heart failure, severe valve disease, uncontrolled sepsis
- Path rejoins step 14Shared downstream outcome
- GOV2 or IGV1
17Action GOV2 or isolated gastric varices (IGV1): tissue adhesive
Cyanoacrylate or thrombin injection, or EUS-guided coiling, by local expertise.
- After haemostasis: portal venous phase CT to plan definitive therapy
- Definitive therapy: TIPS (with or without variceal embolisation) as soon as possible is preferred
- TIPS contraindicated: transvenous obliteration (e.g. BRTO), endoscopic or surgical therapy; decide with hepatology, endoscopy and interventional radiology
- Path rejoins step 11Shared downstream outcome
- Non-variceal source
18Outcome Non-variceal source: manage as non-variceal upper GI bleeding
Stop the vasoactive drug. Continue antibiotic prophylaxis. Manage the lesion per the non-variceal bleeding pathway.
Guideline Source
Baveno VIII - Advancing Consensus in Portal Hypertension (Baveno VIII Faculty, J Hepatol 2026)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults with cirrhosis only. Not for children, non-cirrhotic portal hypertension or ectopic varices; in pregnancy get specialist advice.
- Australian terlipressin is labelled as terlipressin base (0.85 mg = 1 mg acetate); overseas doses are acetate. Follow the local protocol.
- Based on Baveno VIII (2026, journal pre-proof), Baveno VII (2022) and the Australian GESA guidelines (2026). Drug doses come from Baveno VII, GESA and product information, as Baveno VIII gives none.
- Pre-emptive and salvage TIPS need a TIPS centre; arrange transfer early.
- Endoscopy needs an experienced endoscopist available 24/7.
Contraindicated Populations
pediatric
Applicable Regions
AUUSEUGlobal
AU: GESA portal hypertension guideline 2026 and GESA TIPS recommendations 2026 largely align with Baveno VII and VIII; the TIPS recommendations add MELD 19 or more at first endoscopy as a pre-emptive TIPS criterion. Terlipressin (ARTG) is labelled as base: 1.7 mg every 4 h, course no more than 48 h per PI.
EU: Baveno VIII (2026) is the current European consensus; unrevised Baveno VII statements remain valid.
US: AASLD 2024 portal hypertension guidance aligns with Baveno VII; US terlipressin doses are stated as acetate.
Version 2Next review: 2027-09-30
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Frequently Asked Questions
What is the Acute Variceal Bleeding in Cirrhosis (Baveno VIII)?
The Acute Variceal Bleeding in Cirrhosis (Baveno VIII) is a emergency clinical algorithm for Gastroenterology. It provides a structured decision tree to guide clinical decision-making, based on Baveno VIII - Advancing Consensus in Portal Hypertension (Baveno VIII Faculty, J Hepatol 2026).
What guideline is the Acute Variceal Bleeding in Cirrhosis (Baveno VIII) based on?
This algorithm is based on Baveno VIII - Advancing Consensus in Portal Hypertension (Baveno VIII Faculty, J Hepatol 2026) (DOI: 10.1016/j.jhep.2026.07.030).
What are the limitations of the Acute Variceal Bleeding in Cirrhosis (Baveno VIII)?
Known limitations include: Adults with cirrhosis only. Not for children, non-cirrhotic portal hypertension or ectopic varices; in pregnancy get specialist advice.; Australian terlipressin is labelled as terlipressin base (0.85 mg = 1 mg acetate); overseas doses are acetate. Follow the local protocol.; Based on Baveno VIII (2026, journal pre-proof), Baveno VII (2022) and the Australian GESA guidelines (2026). Drug doses come from Baveno VII, GESA and product information, as Baveno VIII gives none.; Pre-emptive and salvage TIPS need a TIPS centre; arrange transfer early.; Endoscopy needs an experienced endoscopist available 24/7.. Individual patient factors may require deviation from these recommendations.
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