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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 6 units 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), a urinary catheter should be inserted and consideration given to central line insertion.
  • Consider admission to HDU.
  • Correction of clotting abnormalities related to chronic liver disease with fresh frozen plasma (FFP) has been associated with a poorer outcome in variceal bleeding and should only be considered in the event that there is failure to achieve haemostasis endoscopically. 
  • FFP and fibrinogen should not be used prophylactically i.e. pre-procedure.
  • A platelet count of ≥50x109/L is sufficient to achieve haemostasis for all procedures and is the threshold for considering correction if ongoing active bleeding.
  • Do not give tranexamic acid.
  • Transfuse packed red cells at a threshold of 70g/L (<80g/L if known ischaemic heart disease), aiming for Hb 70-90g/L. Higher transfusion thresholds increase re-bleeding and mortality.
  • Resuscitate with blood (noting Hb targets above) or crystalloid aiming to maintain 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 the 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 or significant peripheral vascular disease) start:

    Terlipressin acetate 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 is 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 co-trimoxazole IV 960mg 12 hourly. Continue antibiotics for 48 hours after cessation of bleeding (observe IV to oral switch as appropriate).

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.
  • Give advice on alcohol intake if appropriate - abstinence alone can reduce the portal pressure.

 

Guideline reviewed: August 2024

Page last updated: August 2024