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Management of Suspected Variceal Bleeding

Assessment

  • Check pulse and BP (including postural drop if not hypotensive).
  • Assess for stigmata of chronic liver disease.
  • Check FBC, coagulation, U&Es and LFTs.
  • Cross-match 6units of blood.

Management

The following management plan should be instituted in all patients with suspected variceal haemorrhage on the basis of having evidence of chronic liver disease and evidence of a significant gastrointestinal bleed prior to the diagnosis of variceal bleed being confirmed.

  • If patient is shocked (pulse >100bpm, systolic BP <100mmHg and evidence of bleeding) should have a urinary catheter inserted and consideration of central line insertion.
  • Consider admission to HDU.
  • Correct any clotting and platelet abnormality (discuss with haematology).
  • Resuscitate with blood or colloid aiming to maintain Hb >70g/L, pulse <100bpm, systolic BP >90–100mmHg, central venous pressure (CVP) of 8–10cm and urine output >30ml/hour. Resuscitation and transfusion requirements also depend on patient's age and co-morbidities.
  • Start appropriate drug therapy (see 'Drug therapy' section of this guideline).
  • If ascites is present perform an ascitic tap.
  • Seek help from seniors:
    • If stable should be listed for urgent endoscopy.
    • If unstable, liaise with on-call endoscopist. A Sengstaken tube should only be inserted in exceptional circumstances by an experienced member of staff. Anaesthetic support to protect the airway followed by transfer to ITU may be necessary.

Drug therapy

  • Unless contraindication (cardiovascular disease) start:

    Terlipressin 2mg by IV bolus followed by 2mg every 4 to 6 hours until bleeding is controlled, for up to 48 hours.

    Octreotide can be used if terlipressin contraindicated, but this use is unlicensed and therefore should be discussed with seniors first.

  • Start antibiotics :

    Co-amoxiclav IV 1.2g every 8 hours or if true penicillin/ beta-lactam allergy ciprofloxacin IV 400mg 12 hourly. Continue antibiotics for 48 hours after cessation of bleeding (observe IV to oral switch).

Management once stable

  • Enter into a variceal eradication programme - discuss with gastroenterologist.
  • Start carvedilol oral 6.25mg once daily and titrate up to maintenance dose of 12.5mg after one week if tolerated.
  • If carvedilol not suitable, start propranolol oral 40mg twice daily if no contraindication and titrate up to 160mg once daily sustained release preparation if tolerated.
  • Give advice on alcohol intake if appropriate - abstinence alone can reduce the portal pressure.

 

Guideline reviewed: June 2021

Page updated: March 2022