ICU · GI/Nutrition

Acute variceal haemorrhage

Also known as Variceal bleed · Oesophageal varices · Gastric varices · Band ligation · Terlipressin · Sengstaken-Blakemore · TIPS · TIPSS

Acute variceal haemorrhage is life-threatening bleeding from oesophageal or gastric varices that form as a consequence of portal hypertension (cirrhosis the commonest cause). Mortality 15-25% within 6 weeks of the episode. PATHOPHYSIOLOGY: portal venous pressure rises (HVPG over 10 mmHg defines clinically significant portal hypertension; varices bleed above 12 mmHg) → collateral portosystemic circulation → thin-walled varices at the gastro-oesophageal junction and gastric fundus → wall tension rises with radius (Laplace) → rupture when wall stress exceeds tensile strength. MANAGEMENT cascade (ESGE 2022): resuscitate with restrictive transfusion (transfuse when haemoglobin falls below 70 g/L; post-transfusion target 70-90 g/L) → start vasoactive drug at presentation (terlipressin, octreotide or somatostatin, continued for up to 5 days) AND prophylactic ceftriaxone 1 g IV daily for up to 7 days (antibiotics reduce all-cause mortality RR 0.79, rebleeding RR 0.53) → endoscopy within 12 h with band ligation for oesophageal varices, cyanoacrylate glue for cardiofundal varices → balloon tamponade as a temporary bridge → salvage TIPS for refractory bleeding; early pre-emptive TIPS within 72 h (preferably within 24 h) for high-risk patients (Child-Pugh C up to 13, or Child-Pugh B over 7 with active bleeding at endoscopy).