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Variceal hemorrhage

Key sources
The following summarized guidelines for the evaluation and management of variceal hemorrhage are prepared by our editorial team based on guidelines from the American Association for the Study of Liver Diseases (AASLD 2023; 2017), the American Gastroenterological Association (AGA 2023; 2021), the European Association for the Study of the Liver (EASL 2023; 2018), the European Society of Gastrointestinal Endoscopy (ESGE 2022), the British Society for Haematology (BSH 2022), the Advancing Liver Therapeutic Approaches Consortium (ALTA 2021), the British Society of Gastroenterology (BSG 2015), and the American Society for Gastrointestinal Endoscopy (ASGE 2014).


1.Screening and diagnosis

Screening for varices
As per EASL 2018 guidelines:
Perform upper gastrointestinal endoscopy to screen for gastroesophageal varices in patients with decompensated liver cirrhosis, unless previously diagnosed and treated. Report the presence, size and presence of red wale marks.
Perform repeated upper gastrointestinal endoscopy every year in patients with liver cirrhosis without varices on screening upper gastrointestinal endoscopy if the etiological factor persists and/or the state of liver decompensation continues. Consider prolonging the screening interval in the remaining patients.
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2.Classification and risk stratification

Risk stratification: obtain risk stratification in patients with advanced chronic liver disease presenting with suspected acute variceal bleeding according to theChild-Pugh score and MELD score, and by documentation of active/inactive bleeding at the time of upper gastrointestinal endoscopy.

3.Diagnostic investigations

Upper gastrointestinal endoscopy
As per ESGE 2022 guidelines:
Obtain endoscopic evaluation within 12 hours from the time of presentation in patients with suspected variceal hemorrhage, provided the patient has been hemodynamically resuscitated.
Administer IV erythromycin 250 mg, if not contraindicated, 30-120 minutes before gastrointestinal endoscopy in patients with suspected acute variceal hemorrhage.

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  • Evaluation for portal hypertension

4.Medical management

Intravenous fluids: initiate prompt volume replacement with colloids and/or crystalloids to restore and maintain hemodynamic stability.
do not use starch for volume replacement.

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  • Vasoactive agents

  • Tranexamic acid

  • Antibiotic prophylaxis

  • Lactulose

  • PPIs

  • Medications to avoid

5.Inpatient care

Inpatient monitoring: as per BSH 2022 guidelines, pay special attention to heightened risks of raising vascular pressures with excessive plasma transfusions and the limitations of standard coagulation tests to monitor coagulation status in patients with liver disease.

6.Therapeutic procedures

Blood product transfusion: as per ESGE 2022 guidelines, use a restrictive RBC transfusion strategy, with a hemoglobin threshold of ≤ 70 g/L prompting RBC transfusion in hemodynamically stable patients with acute upper gastrointestinal hemorrhage and no history of CVD. Set a post-transfusion target hemoglobin of 70-90 g/L.

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  • Endoscopic variceal ligation

  • Endoscopic sclerotherapy

  • TIPS (indications)

  • TIPS (technical considerations)

  • Retrograde transvenous obliteration

  • Antegrade transvenous obliteration

  • Balloon tamponade

  • Sengstaken-Blakemore tube

7.Specific circumstances

Pregnant patients: initiate or continue β-blockers during pregnancy for primary or secondary prophylaxis of variceal hemorrhage, provided there are no contraindications.
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  • Patients with gastric varices (prevention of bleeding)

  • Patients with gastric varices (management of bleeding)

  • Patients with gastric varices (post-treatment surveillance)

  • Patients with ectopic varices

  • Patients with compensated cirrhosis

  • Patients with acute-on-chronic liver failure

  • Patients with HCC

8.Preventative measures

Primary prevention: as per AASLD 2023 guidelines, do not perform TIPS placement for the primary prevention of variceal bleeding (including bleeding from gastrofundal varices).

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  • Secondary prevention

9.Follow-up and surveillance

Serial assessment of HVPG: avoid monitoring changes in hepatic venous pressure gradient routinely. Recognize that noninvasive tests do not correlate well with changes in hepatic venous pressure gradient.

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  • Post-treatment surveillance (after endoscopic therapy)

  • Post-treatment surveillance (after TIPS)

  • Post-treatment surveillance (after RTO)

  • Post-treatment surveillance (after ATO)

  • Management of refractory disease