Variceal Bleed

Hemorrhage from portosystemic varices (esophageal > gastric) due to portal hypertension

Symptoms / Associated Sx

  • Sudden large-volume hematemesis (bright red blood)

  • Melena or hematochezia if brisk bleed

  • Hemodynamic instability: tachycardia, hypotension, syncope

  • Stigmata of chronic liver disease: jaundice, spider angiomata, palmar erythema, gynecomastia, asterixis

  • Abdominal distension (ascites), splenomegaly

Denies

  • Prior NSAID use without liver disease (shifts toward PUD)

  • Preceding forceful retching (rules out Mallory-Weiss as primary)

  • Odynophagia, dysphagia (rules out esophageal malignancy)

Social History (SHx)

Heavy alcohol use (alcoholic cirrhosis), IV drug use (viral hepatitis → cirrhosis), known cirrhosis, prior variceal bleed, prior banding/sclerotherapy.

Main Etiology

  • Portal hypertension (HVPG >12 mmHg) → varices develop

  • Cirrhosis — most common (alcoholic, viral, NASH, autoimmune)

  • Non-cirrhotic portal HTN: portal vein thrombosis, schistosomiasis, Budd-Chiari

  • Gastric varices: portal HTN or isolated splenic vein thrombosis

Most Common DDx

  • PUD bleeding (NSAID/H. pylori history; no liver disease; BUN:Cr >20; EGD shows ulcer not varices)

  • Mallory-Weiss tear (preceded by retching; no liver disease signs; EGD shows mucosal tear at GEJ)

  • Portal hypertensive gastropathy (chronic oozing from congested gastric mucosa in cirrhosis; EGD shows "snake skin" or "mosaic" pattern, not discrete variceal columns)

  • Gastric antral vascular ectasia — GAVE (chronic oozing, "watermelon stomach" on EGD; associated with cirrhosis, scleroderma, CKD; treated with APC not banding)

  • Dieulafoy lesion (large submucosal vessel eroding mucosa; no liver disease; often requires multiple EGDs to find)

  • Aortoenteric fistula (prior aortic graft; massive hemorrhage; CT angiography confirms)

DATA

  • CBC, BMP/CMP, coagulation panel, type and crossmatch, lactate

  • Blood cultures × 2, LFTs, albumin, ammonia (baseline HE)

  • EGD — urgent within 12h; band ligation preferred over sclerotherapy

  • MELD score calculation

Home Meds

  • Non-selective beta-blockers (hold acutely; restart after stabilization)

  • Diuretics (hold during active bleed)

  • Lactulose (continue if encephalopathy present)

  • Anticoagulants (hold; reversal if massive bleed)

Plan

  • Resuscitation (restrictive): 2 large-bore IVs; pRBCs to Hgb 7–8 (avoid overtransfusion — raises portal pressure); platelets if <50k; airway protection if massive hematemesis or AMS → intubate before EGD

  • Vasoactive therapy (start immediately before EGD): Octreotide 50 mcg IV bolus → 50 mcg/hr × 3–5 days

  • Antibiotic prophylaxis (start immediately — reduces mortality): Ceftriaxone 1 g IV daily × 7 days

  • Endoscopy: EGD within 12h; EVL (band ligation) first-line; Erythromycin 250 mg IV 30–90 min before EGD

  • Refractory/recurrent: Repeat EVL → early TIPS (<72h) for Child B/C; balloon tamponade as bridge only

  • Treat HE: lactulose + rifaximin; ICU monitoring; hepatology consult; transplant evaluation

  • Serial CBC q6h; daily BMP/LFTs/coags; trend ammonia and fever curve

  • PT/OT when stabilized

  • Discharge: Non-selective BB (propranolol 20–40 mg BID or carvedilol 6.25 mg BID) + EVL program q2–4 weeks; alcohol cessation; hepatology 1–2 weeks; MELD reassessment; transplant if indicated

Red Flags

  • Active hematemesis + airway compromise → intubate before EGD

  • HR >100 + SBP <90 → ICU; avoid overtransfusion

  • Failed 2 endoscopic sessions → early TIPS (<72h) — reduces mortality in Child B/C

  • AMS + cirrhosis + GI bleed → HE → lactulose + rifaximin

  • Fever + cirrhosis → SBP → diagnostic paracentesis

  • Rebleed within 5 days → highest-risk period → escalate to TIPS

Senior IM Resident Pearls

  • Restrictive transfusion (Hgb 7–8): Overtransfusion raises portal pressure and worsens bleeding — Villanueva trial landmark evidence

  • INR in cirrhosis is unreliable — balanced pro- and anticoagulant reduction; use TEG/thromboelastometry if available

  • Early TIPS (<72h): Child B with active bleed or Child C (<14 pts) — Garcia-Pagan trial; significantly reduces rebleed and mortality

  • Antibiotics reduce mortality — not just infection; ceftriaxone preferred over fluoroquinolones due to resistance

  • Common mistake: Continuing beta-blockers during acute bleed — blunts compensatory tachycardia; hold acutely

  • Common mistake: Forgetting SBP prophylaxis — 20–40% infection risk in cirrhotic GI bleed; antibiotics are standard of care

ORDERS

Labs

Admission Labs

  • CBC with diff

  • CMP

  • PT/INR

  • PTT

  • Type & Screen

  • Type & Cross (4–6 units PRBC)

  • Lactate

  • LFTs

  • Albumin

  • Magnesium

  • Phosphorus

  • Blood cultures ×2

Additional Labs

  • Ammonia (baseline HE assessment)

  • Ethanol level

  • Viral hepatitis panel if etiology unclear

  • AFP if concern for HCC

  • TEG/ROTEM if available (better than INR in cirrhosis)

Trending Labs

  • CBC q6 hr

  • BMP daily

  • LFTs daily

  • PT/INR daily

  • Ammonia daily if HE

  • Hgb/Hct after transfusions

Imaging

Usually Not Needed Initially

  • EGD is diagnostic and therapeutic

If Source Unclear

  • CTA Abdomen/Pelvis

Cirrhosis Workup

  • RUQ Ultrasound with Doppler

    • Portal vein thrombosis

    • Budd-Chiari

    • Ascites

If Ascites Present

  • Bedside ultrasound prior to paracentesis

Procedures

Immediately

  • Two large-bore IVs (14–16 gauge)

  • Telemetry

  • Continuous pulse ox

  • Strict I&O

Airway

  • Intubate before EGD if:

    • Massive hematemesis

    • AMS

    • Unable to protect airway

Definitive Procedure

  • EGD within 12 hr

During EGD

  • Endoscopic variceal ligation (EVL/banding)

  • Sclerotherapy if banding unavailable

If Ascites + Fever/AMS

  • Diagnostic paracentesis

    • Cell count

    • Differential

    • Albumin

    • Protein

    • Culture

Rescue Procedures

  • Balloon tamponade (Sengstaken-Blakemore/Minnesota tube)

    • Bridge only

Definitive Rescue

  • TIPS (Transjugular Intrahepatic Portosystemic Shunt)

Medications

Vasoactive Therapy (Start Immediately)

Octreotide

  • 50 mcg IV bolus

  • Then 50 mcg/hr infusion

  • Continue x3–5 days

Antibiotics (Standard of Care)

First-Line

  • Ceftriaxone 1 g IV daily x7 days

Alternative

  • Cefotaxime 2 g IV q8h

Severe Beta-Lactam Allergy

  • Ciprofloxacin 400 mg IV q12h

Resuscitation

Fluids

  • LR/NS cautiously

  • Avoid excessive crystalloid

Blood Products

PRBC

  • Goal Hgb 7–8

  • Avoid Hgb >9

Platelets

  • Give if <50,000

FFP

  • Active bleeding with severe coagulopathy

Cryoprecipitate

  • Fibrinogen <100

Hepatic Encephalopathy

Lactulose

  • 20–30 g PO q2–4 hr until bowel movement

  • Then titrate to 3–4 BM/day

Rifaximin

  • 550 mg PO BID

Pre-EGD

Erythromycin

  • 250 mg IV once

  • 30–90 min before EGD

Secondary Prevention (After Stabilization)

Propranolol

  • 20–40 mg PO BID

OR

Carvedilol

  • 6.25 mg PO BID

Start after bleeding controlled.

Hold Medications

During Active Bleed

  • Propranolol

  • Nadolol

  • Carvedilol

  • Diuretics

  • Warfarin

  • DOACs

  • Heparin

  • Aspirin

  • Clopidogrel

  • NSAIDs

Consults

Gastroenterology (STAT)

  • Urgent EGD

  • Band ligation

ICU

  • All unstable patients

  • Massive hematemesis

  • Intubation

  • Vasopressors

Hepatology

  • Cirrhosis management

  • TIPS evaluation

  • Transplant evaluation

Interventional Radiology

  • TIPS

  • Failed endoscopy

Transplant Team

  • MELD elevation

  • Child C disease

  • Recurrent variceal bleeding

PT/OT

  • Deconditioning

Addiction Medicine

  • Alcohol cessation

Nursing Orders

Monitoring

  • ICU or step-down

  • Telemetry

  • Continuous pulse ox

  • Strict I&O

  • Daily weights

Diet

  • NPO

  • Advance after hemostasis

Notify Physician Immediately

  • SBP <90

  • HR >110

  • Recurrent hematemesis

  • New AMS

  • Increasing oxygen requirement

Follow-Up Studies

Daily

  • CBC

  • BMP

  • LFTs

  • INR

Calculate

  • MELD-Na

  • Child-Pugh

Follow

  • Blood cultures

  • Ascitic cultures

  • EGD findings

Escalation Criteria

Immediate Intubation

  • Active hematemesis

  • GCS <8

  • Inability to protect airway

ICU

  • Shock

  • Vasopressor requirement

  • Massive transfusion

Early TIPS (<72 hr)

  • Child C (<14 points)

  • Child B with active bleeding

  • Rebleeding despite banding

Balloon Tamponade

  • Massive uncontrolled bleed

  • Bridge to TIPS

Surgery (Rare)

  • Failed TIPS

  • Failed IR

  • Catastrophic hemorrhage