Acute Variceal Hemorrhage Management (Baveno VII 2022)

Algorithm Steps

1. ▶

   Start

   Suspected Variceal Hemorrhage

   Patient with known/suspected cirrhosis presenting with hematemesis or melena

   1. ●

      Action

      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)
      1. ●

         Action

         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
         1. ◆

            Decision

            Timing of Endoscopy

            EGD within 12 hours of presentation

            • After initial stabilization
            • Erythromycin 250mg IV 30-120 min before
            • Improves visualization
            1. ●

               Action

               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
               1. ◆

                  Decision

                  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
                  1. ●

                     Action

                     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
                     1. ✓

                        Outcome

                        Bleeding Controlled

                        Continue secondary prophylaxis with NSBB + EVL until variceal eradication

                     2. ✓

                        Outcome

                        Evaluate for Transplant

                        Refer to transplant center if decompensated cirrhosis

                  2. ●

                     Action

                     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
                     1. ⚠

                        Warning

                        Rescue TIPS

                        For refractory/recurrent bleeding despite endoscopic therapy

                        • Failure of endoscopic hemostasis
                        • Rebleeding despite optimal therapy
                        • Bridge to transplant if appropriate
            2. ●

               Action

               Gastric Varices (GOV2/IGV)

               Cyanoacrylate injection or TIPS

               • Tissue adhesive (cyanoacrylate) injection
               • OR Early TIPS if available
               • EVL NOT effective for fundal varices
      2. ●

         Action

         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
      3. ⚠

         Warning

         ⚠️ Airway Protection

         Consider intubation if massive hematemesis, altered mental status, or encephalopathy