Suspected Variceal Hemorrhage
Patient with known/suspected cirrhosis presenting with hematemesis or melena
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GastroenterologyEmergency
Acute Variceal Hemorrhage Management (Baveno VII 2022)
Acute Variceal Hemorrhage Management (Baveno VII 2022): Suspected Variceal Hemorrhage → Initial Resuscitation → Vasoactive Therapy → Timing of Endoscopy...
Pathway Overview
14 steps
Algorithm Steps
14 total
01Start 02Action Initial Resuscitation
Hemodynamic stabilization and early pharmacotherapy
- IV access x2, type and cross
- Restrictive transfusion: target Hb 7-8 g/dL
- Avoid over-resuscitation (increases portal pressure)
- Start vasoactive drugs IMMEDIATELY (before EGD)
03Action Vasoactive Therapy
Reduce portal pressure
- Octreotide 50mcg bolus (optional), then 25-50mcg/hr IV continuous
- OR Terlipressin 2mg IV q4h x 48h, then reduce to 1mg q4h
- Continue for 2-5 days
- Start BEFORE endoscopy
04Decision Timing of Endoscopy
EGD within 12 hours of presentation
- After initial stabilization
- Erythromycin 250mg IV 30-120 min before
- Improves visualization
05Action Esophageal Variceal Ligation (EVL)
First-line endoscopic therapy for esophageal varices
- Band ligation preferred over sclerotherapy
- 4-8 bands per session typical
- Repeat q2-4 weeks until eradication
06Decision Assess Rebleeding Risk
High-risk features for early rebleeding
- Child-Pugh C or MELD >19
- Active bleeding at endoscopy
- HVPG >20 mmHg (if measured)
- Hepatic encephalopathy
07Action Early Pre-emptive TIPS
Within 72 hours (ideally 24h) for high-risk patients
- Child-Pugh C (10-13 points)
- OR Child-Pugh B with active bleeding
- Covered PTFE stents preferred
- Reduces rebleeding and mortality
08Outcome Bleeding Controlled
Continue secondary prophylaxis with NSBB + EVL until variceal eradication
09Outcome Evaluate for Transplant
Refer to transplant center if decompensated cirrhosis
10Action Standard Medical Therapy
Continue vasoactive drugs and NSBB after acute phase
- Complete 5 days of vasoactive therapy
- Start NSBB (propranolol/carvedilol) after day 5
- Schedule EVL sessions q2-4 weeks
- PPI for banding ulcers
11Warning Rescue TIPS
For refractory/recurrent bleeding despite endoscopic therapy
- Failure of endoscopic hemostasis
- Rebleeding despite optimal therapy
- Bridge to transplant if appropriate
- Path rejoins step 09Shared downstream outcome
- Path rejoins step 08Shared downstream outcome
12Action Gastric Varices (GOV2/IGV)
Cyanoacrylate injection or TIPS
- Tissue adhesive (cyanoacrylate) injection
- OR Early TIPS if available
- EVL NOT effective for fundal varices
- Path rejoins step 06Shared downstream outcome
13Action Antibiotic Prophylaxis
Reduce infection and rebleeding
- Ceftriaxone 1g IV q24h (preferred in advanced cirrhosis)
- OR Norfloxacin 400mg PO BID (if able to take PO)
- Duration: 7 days
- Reduces mortality
- Path rejoins step 04Shared downstream outcome
14Warning ⚠️ Airway Protection
Consider intubation if massive hematemesis, altered mental status, or encephalopathy
Guideline Source
Baveno VII - Renewing consensus in portal hypertension
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Requires ICU-level monitoring for unstable patients
- Endoscopy should be performed by experienced endoscopist
- TIPS availability varies by institution
- Antibiotic prophylaxis choice may vary regionally
- Does not address secondary prophylaxis in detail
Contraindicated Populations
pediatric
Applicable Regions
USEUGlobal
EU: Baveno VII is European consensus standard
US: AASLD guidelines align with Baveno VII
Version 1Next review: 2027-01-01
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Glasgow-Blatchford Bleeding Score
Upper GI bleed risk stratification and need for intervention
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Frequently Asked Questions
What is the Acute Variceal Hemorrhage Management (Baveno VII 2022)?
The Acute Variceal Hemorrhage Management (Baveno VII 2022) is a emergency clinical algorithm for Gastroenterology. It provides a structured decision tree to guide clinical decision-making, based on Baveno VII - Renewing consensus in portal hypertension.
What guideline is the Acute Variceal Hemorrhage Management (Baveno VII 2022) based on?
This algorithm is based on Baveno VII - Renewing consensus in portal hypertension (DOI: 10.1016/j.jhep.2022.10.020).
What are the limitations of the Acute Variceal Hemorrhage Management (Baveno VII 2022)?
Known limitations include: Requires ICU-level monitoring for unstable patients; Endoscopy should be performed by experienced endoscopist; TIPS availability varies by institution; Antibiotic prophylaxis choice may vary regionally; Does not address secondary prophylaxis in detail. Individual patient factors may require deviation from these recommendations.
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