In suspected variceal bleeding, start a vasoactive drug such as terlipressin or octreotide as soon as the diagnosis is suspected, before endoscopy. Give prophylactic antibiotics, commonly ceftriaxone in advanced cirrhosis, which reduce infection, rebleeding and death.
Transfuse restrictively, generally aiming for haemoglobin around 7–8 g/dL, because over-transfusion raises portal pressure and rebleeding. Arrange endoscopy within 12 hours once the patient is resuscitated, with band ligation for oesophageal varices. Protect the airway in patients with massive bleeding or encephalopathy.
- Start a vasoactive drug before endoscopy when variceal bleeding is suspected.
- Give prophylactic antibiotics in cirrhosis with gastrointestinal bleeding.
- Use a restrictive transfusion threshold of about 7 g/dL.
- Arrange endoscopy within 12 hours after resuscitation.
Why it matters
Most of what changes survival in variceal bleeding happens before the endoscope is passed.
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