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Variceal hemorrhage

What's new

The European Association for the Study of the Liver (EASL) has published a focused update on transjugular intrahepatic portosystemic shunt (TIPS). For variceal hemorrhage, a salvage TIPS should be considered in patients with cirrhosis and uncontrolled or early recurrent bleeding despite standard treatment. A pre-emptive TIPS within 72 hours is recommended for high-risk patients to improve survival, while selected patients may still benefit beyond this window. In patients with a first episode of bleeding who do not meet high-risk criteria but have grade 2 ascites or portal vein thrombosis, TIPS may be the preferred option. TIPS is also suggested as a first-line alternative in bleeding from gastric or ectopic varices, particularly type 2 gastroesophageal or type 1 isolated gastric varices, and may be considered for portal hypertensive gastropathy refractory to standard therapy. .

Guidelines

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 European Association for the Study of the Liver (EASL 2025,2023,2018), the American Association for the Study of Liver Diseases (AASLD 2023,2017), the American Gastroenterological Association (AGA 2023,2021), the European Society of Anaesthesiology and Intensive Care (ESAIC 2023), ...
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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.
B
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.
B
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Classification and risk stratification

Risk stratification: as per ESGE 2022 guidelines, obtain risk stratification in patients with advanced chronic liver disease presenting with suspected acute variceal bleeding according to the Child-Pugh score and MELD score, and by documentation of active/inactive bleeding at the time of upper gastrointestinal endoscopy.
A
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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.
B
Administer IV erythromycin 250 mg, if not contraindicated, 30-120 minutes before gastrointestinal endoscopy in patients with suspected acute variceal hemorrhage.
A
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  • Evaluation for portal hypertension

Medical management

General principles
As per ESAIC 2023 guidelines:
Manage acute variceal bleeding by a multidisciplinary team using a specific multimodal protocol for upper gastrointestinal bleeding.
B
Perform early interventional endoscopy along with vasoactive agents producing splanchnic vasoconstriction (somatostatin, terlipressin, or octreotide) in patients with acute variceal hemorrhage.
B
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  • Intravenous fluids

  • Vasoactive agents

  • Tranexamic acid

  • Antibiotic prophylaxis

  • Lactulose

  • PPIs

  • Medications to avoid

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.
B
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Therapeutic procedures

Blood product transfusion
As per ESAIC 2023 guidelines:
Use a restrictive transfusion strategy aiming for a hemoglobin level of 7-8 g/dL in hemodynamically stable patients with upper gastrointestinal bleeding.
B
Recognize that use of FFP in patients with acute variceal hemorrhage is associated with increased mortality, failure to control bleeding, and longer length of stay.
B
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  • Endoscopic variceal ligation

  • Self-expandable metallic stents

  • Endoscopic sclerotherapy

  • TIPS (indications)

  • TIPS (technical considerations)

  • Retrograde transvenous obliteration

  • Antegrade transvenous obliteration

  • Balloon tamponade

  • Sengstaken-Blakemore tube

Specific circumstances

Pregnant patients: as per EASL 2023 guidelines, initiate or continue β-blockers during pregnancy for primary or secondary prophylaxis of variceal hemorrhage, provided there are no contraindications.
B
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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

Preventative measures

Primary prevention, beta-blockers and endoscopic variceal ligation: as per ESAIC 2023 guidelines, initiate β-blockers or perform endoscopic variceal ligation as primary prophylaxis for bleeding in patients with high-risk esophageal varices.
B
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  • Primary prevention (nitrates)

  • Primary prevention (PPIs)

  • Primary prevention (TIPS)

  • Primary prevention (sclerotherapy)

  • Secondary prevention

Follow-up and surveillance

HVPG monitoring: as per AASLD 2017 guidelines, avoid monitoring changes in hepatic venous pressure gradient routinely. Recognize that noninvasive tests do not correlate well with changes in hepatic venous pressure gradient.
D
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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