Management of Suspected Variceal Bleeding
- 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.
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 CVP 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, CVP of 8–10cm and urine output greater than 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.
Unless contraindication (cardiovascular disease) start:
Terlipressin 2mg by IV bolus followed by 1–2mg 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 - use broad spectrum antibiotic cover:
Co-amoxiclav IV 1.2g every 8 hours (or clarithromycin IV 500mg every 12 hours if penicillin allergy). If antibiotic therapy not otherwise required, continue for 7 days (when appropriate observe IV to oral switch).
Management once stable
- Enter into a variceal eradication programme - discuss with gastroenterologist.
- 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.