Upper gastrointestinal bleed — variceal pathway

Working diagnosis. Suspected acute variceal upper gastrointestinal bleed on a background of cirrhosis — massive haematemesis with shock. Pathway-specific therapy starts on suspicion, before endoscopy.^[3]

ABCDE resuscitation.

• Airway: high aspiration risk; protect before endoscopy if ongoing torrential haematemesis, falling GCS, or encephalopathy.
• Breathing: high-flow oxygen as needed; prepare suction.
• Circulation: two large-bore cannulae; crossmatch; cautious crystalloid then blood products; urinary catheter; serial lactate/VBG.
• Restrictive transfusion: threshold 7 g/dL (consensus below 80 without cardiac disease). Liberal below 9 raises the portal-pressure gradient within 5 days; restriction: survival 95 vs 91 percent, rebleed 10 vs 16 percent.^[2]
• Correct coagulopathy for life-threatening bleed per local massive-haemorrhage protocol.

Pre-endoscopic variceal drugs (both on arrival).

• Vasoactive drug immediately for up to 5 days to prevent early rebleed — terlipressin preferred where available for its safety profile.^[3]
• Prophylactic antibiotics on arrival — mortality RR 0.79, infections RR 0.36, rebleed RR 0.53; ceftriaxone 1 g daily beat norfloxacin 11 vs 33 percent in advanced cirrhosis (7-day trial); no regimen superior overall.^[9][10]

Risk stratification. Glasgow-Blatchford from admission bloods and bedside — this patient is high-risk (7 or more predicts endoscopic treatment at 80 percent sensitivity); 1 or less may avoid admission at 98.6 percent sensitivity.^[1][12]

Definitive therapy. Urgent endoscopy with band ligation for oesophageal varices; mild early rebleed may take a second endoscopic course, severe rebleed takes covered TIPSS first. Continue vasoactive drug and antibiotic.^[3]

Rescue if uncontrolled. Balloon tamponade as temporary bridge to TIPSS in refractory bleeding. Discuss early covered TIPSS within 72 hours for Child-Pugh C under 14 or B with active bleeding — failure 1/32 vs 14/31, survival 86 vs 61 percent.^[3][7]

Disposition. HDU/ICU after stabilisation; avoid routine tranexamic acid — HALT-IT 12,009 patients: death 4 vs 4 percent (RR 0.99), venous events higher.^[11]