01Approach to the Critical Patient/attcp61

Immediate stabilization

›Airway management priorities

›Intubate if altered mental status, massive hematemesis, or high aspiration risk

›Rapid sequence intubation with in-line suction preparation

›Class I recommendation for early intubation in encephalopathic patients

›Two large-bore IV access minimum

›16-gauge or larger bilateral antecubital placement

›Central venous access if peripheral inadequate

›Avoid aggressive crystalloid resuscitation

›Worsens portal pressure

›Increases rebleeding risk

›Resuscitation targets

›Restrictive transfusion strategy

›Haemoglobin target 70 g/l (7 g/dL) in most patients

›Higher threshold 80 g/l if active coronary disease or haemodynamic shock

›Hemodynamic endpoints

›MAP >= 65 mmHg

›Urine output >= 0.5 ml/kg/hour

›Avoid liberal FFP transfusion

›INR does not predict hemostatic dysfunction in cirrhosis

›Liberal FFP worsens portal pressure and survival

Pharmacologic bridge

›Vasoactive therapy — initiate before endoscopy

›Octreotide 50 mcg IV bolus then 25 to 50 mcg per hour infusion

›Only vasoconstrictor approved in North America for variceal bleeding

›Continue for 2 to 5 days post-endoscopy

›Terlipressin 2 mg IV every 4 to 6 hours for 24 to 48 hours then 1 mg every 4 to 6 hours

›Not approved in North America

02History/hx78

Bleeding presentation

›Hematemesis characterization

›Bright red blood emesis

›Strongly predicts variceal source OR 4.6

›Active high-volume hemorrhage indicator

›Coffee-ground emesis

›Subacute or lower-volume bleeding

›Peptic ulcer bleeding overlap

›Melena or hematochezia

›Volume and frequency of episodes

›Black tarry stool versus maroon stool

›Hemodynamic symptoms

›Syncope or presyncope

›Haemodynamic compromise indicator

›Orthostatic lightheadedness

›Volume of blood loss estimate

›Clots passed

›Saturated clothing or bedding

Liver disease history

›Known cirrhosis and etiology

›Alcohol use disorder

›Quantity and duration

›Last drink date

›Chronic viral hepatitis B or C

›Treatment status and viral load

›NAFLD or NASH cirrhosis

›Metabolic syndrome comorbidities

›Other etiologies

03Physical Exam/exam55

Vitals and haemodynamic assessment

›Haemodynamic stability snapshot

›Heart rate

›Tachycardia > 100 as active bleeding marker

›Orthostatic heart rate increase > 20 beats per minute

›Blood pressure

›SBP < 90 mmHg as shock threshold

›Orthostatic drop > 20 mmHg SBP

›Respiratory rate and oxygen saturation

›Aspiration risk screen

›Hepatopulmonary syndrome consideration

›Temperature

›Fever suggesting infection as precipitant of bleeding

Stigmata of chronic liver disease

›Cutaneous and peripheral findings

›Spider angiomata

›Distribution on upper thorax and face

›Number correlates with severity of portal hypertension

›Palmar erythema

›Erythema of thenar and hypothenar eminences

›Gynecomastia

›Oestrogen excess from impaired hepatic metabolism

›Caput medusae

›Dilated periumbilical veins indicating portal hypertension

›Jaundice

›Scleral icterus

›Skin yellowing

›Temporal wasting and sarcopenia

04Differential Diagnosis/ddx44

Life-threatening upper GI bleeding

›Variceal bleeding sources

›Esophageal varices

›ICD-10 I85.01 acute bleeding

›ICD-10 I85.11 with secondary bleeding

›Gastric varices

›Gastro-oesophageal varices type 1 and 2

›Isolated gastric varices type 1 requiring cyanoacrylate injection

›Ectopic varices

›Duodenal or rectal variceal bleeding

›Less common

›Non-variceal life threats

›Peptic ulcer disease

›Most common cause of UGIB overall

›Up to 38% of UGIB in cirrhotics is non-variceal

›Aortoenteric fistula

›Prior aortic surgery history

›Catastrophic haemorrhage pattern

›Dieulafoy lesion

›Rare vascular malformation

›Massive haemorrhage without mucosal ulceration

Common mimics

›Portal hypertensive conditions

›Portal hypertensive gastropathy

›Chronic insidious blood loss

›Anaemia rather than acute haemorrhage

›Gastric antral vascular ectasia

›Watermelon stomach pattern on endoscopy

05Laboratory Tests/lt53

Resuscitation and haemostasis labs

›Type and crossmatch

›Emergency release pRBC availability

›Haemoglobin target 70 g/l guides transfusion

›2 units pRBC on hold minimum

›Platelet transfusion threshold

›Transfuse if < 50 x 10 to the 9 per litre with active bleeding

›Fibrinogen

›DIC suspicion in acute-on-chronic liver failure

›Target > 1.5 g/l

›Coagulation studies

›PT and INR

›Does not reliably predict bleeding risk in cirrhosis

›Child-Pugh score input

›TEG or ROTEM if available

›Functional coagulation assessment superior to INR in cirrhosis

›Guides targeted factor replacement

Liver function and organ assessment

›Hepatic markers

›Bilirubin

›Child-Pugh and MELD score component

›Elevated in decompensation

›Albumin

›Child-Pugh score component

›Nutritional and synthetic function marker

›AST and ALT

›Alcoholic hepatitis pattern AST:ALT ratio > 2:1

›Acute hepatocyte injury overlay

06Diagnostic Tests/dt94

Scoring Systems

›Child-Pugh score

›Variables

›Bilirubin level

›Albumin level

›PT prolongation

›Ascites grade

›Encephalopathy grade

›Risk stratification

›Child-Pugh A 5 to 6 points compensated

›Child-Pugh B 7 to 9 points moderate

›Child-Pugh C 10 to 15 points decompensated

›Child-Pugh C highest mortality from variceal bleeding

›MELD score

›Components

›Creatinine in mmol/l

›Bilirubin in mmol/l

›INR

›Clinical use

›Predicts 90-day transplant-free survival

›MELD >= 15 triggers transplant referral consideration

›MELD-Na includes sodium for improved accuracy

›Glasgow Blatchford Score

›UGIB risk stratification

›Blood urea nitrogen

›Haemoglobin

›SBP

›Heart rate

›Comorbidities

›Score 0 low-risk outpatient management possible

›Higher scores predict need for intervention

›SCoPE score for portal vein ultrasound

›Predicts variceal aetiology of UGIB

›AUC 0.843 in emergency department

›Portal vein diameter and flow velocity parameters

›Adjunct to clinical assessment in the ED

MRI

›MRI liver and portal system role

›Fibrosis staging and hepatic architecture

›MR elastography for non-invasive fibrosis quantification

›Superior soft tissue characterisation

›Portal vein assessment

›Portal vein thrombosis characterisation

›Cavernous transformation identification

›Hepatocellular carcinoma detection

›LI-RADS classification system

›HCC surveillance in cirrhotic patients

›Limitations in acute bleeding

›Not indicated in acute variceal haemorrhage

›Patient haemodynamic instability prohibits

›Time delay unacceptable in emergency setting

›MR angiography for vascular anatomy pre-TIPS

›Problem-solving when CT contrast contraindicated

›Elective planning use only

CT

›CT abdomen with contrast indications

›Portal vein thrombosis evaluation

›Required before TIPS procedure

›Triphasic protocol preferred

›Hepatocellular carcinoma assessment

›Vascular anatomy for endovascular planning

›LI-RADS characterisation

›Vascular anatomy pre-TIPS

›Hepatic vein and portal vein mapping

›Splenic and superior mesenteric vein assessment

›CT angiography for refractory bleeding

›Localisation of active extravasation

›Sensitivity 45 to 79% for active extravasation rate > 0.5 ml per minute

›Guides endovascular intervention targeting

›Contrast considerations

›Renal function assessment pre-contrast

›Hepatorenal syndrome risk in cirrhosis

Ultrasound

›Abdominal ultrasound with Doppler — first-line imaging

›Portal vein assessment

›Portal vein diameter > 13 mm predicts portal hypertension

›Decreased portal vein flow velocity

›Portal vein thrombosis screening

›Liver morphology

›Nodular liver surface

›Caudate lobe hypertrophy

›Hepatic parenchymal echogenicity

›Splenomegaly

›Spleen length > 12 cm as portal hypertension marker

›Platelet count to spleen length ratio for variceal prediction

›Ascites quantification

›Free fluid in Morison pouch and pelvis

›Guide for paracentesis planning

›POCUS portal vein assessment in ED

›SCoPE score application

›Portal vein diameter

›Portal vein flow velocity

›Splenomegaly

›AUC 0.843 for variceal aetiology prediction

›Cardiac POCUS for haemodynamic assessment

›Left ventricular function estimation

›IVC assessment for volume responsiveness

›ACEP Level B recommendation for POCUS in UGIB assessment

07Disposition/dispo46

ICU admission criteria

›Mandatory ICU indications

›Active variceal haemorrhage at presentation

›All patients with haemodynamic instability

›Haemoglobin < 70 g/l with ongoing bleeding

›Airway compromise or aspiration risk

›Intubated patients

›Altered mental status with active bleeding

›Haemodynamic shock

›SBP < 90 mmHg despite resuscitation

›Vasopressor requirement

›Hepatic encephalopathy grade 3 or 4

›West Haven grade 3 or 4

›Aspiration risk and airway management

›High-risk features requiring ICU monitoring

›Child-Pugh C cirrhosis

›Highest 6-week mortality

›Concurrent hepatorenal syndrome

›Independent predictor of 42-day mortality

›Active octreotide infusion requirement

›Requires continuous monitoring

Step-down and floor care

›Post-endoscopy monitoring criteria

›Haemodynamically stable following EVL

›No rebleeding for >= 6 hours post-procedure

›Octreotide and antibiotics continuation for 2 to 5 days

›Tolerating nasogastric medications

›Lactulose for encephalopathy prophylaxis

08Treatment/t100

Vasoactive pharmacotherapy

›Octreotide infusion protocol

›Dosing

›50 mcg IV bolus at presentation

›25 to 50 mcg per hour continuous infusion immediately after bolus

›Duration

›2 to 5 days post-endoscopy

›Reduce splanchnic blood flow throughout

›Monitoring

›Blood glucose monitoring due to insulin suppression

›QT monitoring with concurrent erythromycin

›Terlipressin protocol (where available)

›Dosing

›2 mg IV every 4 to 6 hours for first 24 to 48 hours

›Reduce to 1 mg IV every 4 to 6 hours when controlled

›Duration

›Up to 5 days

›Monitoring

›Hyponatraemia

›Peripheral ischaemia in patients with vascular disease

Antibiotic prophylaxis

›Ceftriaxone first-line regimen

›Dosing

›1 g IV every 24 hours

›Start at presentation before endoscopy

›Duration

›Up to 5 days or until discharge

›Evidence

›Reduces short-term mortality from 22.2% to 18.5%

›Preferred over quinolones due to resistance

›Class I recommendation AASLD 2024

›Alternative regimens

›Norfloxacin 400 mg PO twice daily

›For lower-risk patients tolerating oral route

›Increasing quinolone resistance limits utility

›Piperacillin-tazobactam 4.5 g IV every 6 hours

›For patients with suspected gram-negative sepsis overlay

Endoscopic therapy

›Endoscopic variceal ligation (EVL)

›First-line endoscopic treatment for esophageal varices

›Superior to sclerotherapy for acute haemostasis

›Lower complication rate

›Timing

›Urgent EGD within 12 hours of presentation

›Erythromycin 125 to 250 mg IV 30 to 120 minutes pre-endoscopy

›Repeat EVL schedule

›Every 2 to 4 weeks until variceal obliteration

›EGD every 6 to 12 months after obliteration

›Adjunctive endoscopic measures

›Cyanoacrylate injection for gastric varices

›GOV2 and IGV1 type gastric varices

›Different approach from esophageal varices

›Endoscopic sclerotherapy as salvage

›When EVL not technically possible

›Higher complication rate than EVL

Refractory and rescue therapies

›Balloon tamponade

›Sengstaken-Blakemore tube

›Gastric and esophageal balloon inflation

›Maximum 24 to 48 hours to prevent necrosis

›Minnesota tube

›Four-lumen with aspiration port

›Requires intubation before placement

›Self-expanding metal esophageal stent alternative

›Removable esophageal stent

›Fewer aspiration complications than balloon tamponade

›Transjugular intrahepatic portosystemic shunt (TIPS)

›Pre-emptive early TIPS indications

›Child-Pugh B with active bleeding at endoscopy

›Child-Pugh C score 10 to 13

›Within 72 hours of presentation

›Survival benefit

›1-year survival 86% vs 61% without early TIPS

›Class I recommendation Baveno VII

›Salvage TIPS for refractory bleeding

›Failure of two endoscopic sessions

›Haemodynamic instability despite maximal therapy

Primary prophylaxis (no prior bleeding)

›Non-selective beta-blockers (NSBB)

›Carvedilol preferred per Baveno VII

›Starting dose 6.25 mg daily

›Titrate to 12.5 mg daily

›Lower bleeding rates than EVL alone 10% vs 23%

›Propranolol alternative

›20 to 40 mg twice daily

›Titrate to resting HR 55 to 60 beats per minute

›Nadolol alternative

›40 mg once daily

›Titrate to same HR target

›EVL for primary prophylaxis

›Large varices or red wale marks if NSBB contraindicated or intolerant

›Every 2 to 4 weeks until obliteration

›Combined NSBB plus EVL not superior to NSBB alone for primary prophylaxis

Secondary prophylaxis (post-bleeding)

›Combination carvedilol plus serial EVL

›Carvedilol

›6.25 mg daily titrated to 12.5 mg daily

›Start when haemodynamically stable

›Serial EVL

›Every 2 to 4 weeks until obliteration

›Combined approach reduces rebleeding rates

›Rebleeding rate without prophylaxis approximately 60% at 1 year

›TIPS for secondary prophylaxis

›Recurrent bleeding despite optimal NSBB plus EVL

›Salvage procedure

›Liver transplant evaluation concurrent

09Special Populations/sp78

Pregnancy

›Pregnancy-specific considerations

›Physiologic portal pressure increase

›Oestrogen-driven splanchnic vasodilation

›Portal vein flow increases 35 to 50% in normal pregnancy

›Variceal risk peaks in second trimester

›Uterine pressure on portal system

›Highest bleeding risk weeks 20 to 24

›Management modifications in pregnancy

›Octreotide use

›Category B safety data limited

›Use when benefits outweigh risk in life-threatening haemorrhage

›Terlipressin contraindicated in pregnancy

›Uterine contractions

›Foetal ischaemia risk

›EVL preferred endoscopic approach

›Safe in all trimesters

›Second trimester preferred timing for elective procedures

›Antibiotic selection

›Ceftriaxone generally safe in pregnancy

›Avoid quinolones in pregnancy

›Foetal monitoring

›Continuous foetal monitoring during endoscopy after viability

›Supine positioning limitations

›Left lateral tilt preferred

›Obstetrics co-management mandatory

›Preterm labour risk with haemorrhage

Geriatric

›Age-related physiologic differences

›Blunted haemodynamic response

›Tachycardia may be absent despite significant blood loss

›Beta-blocker masking of compensatory tachycardia

›Reduced cardiac reserve

›Higher transfusion threshold may be appropriate 80 g/l

›Aggressive fluid resuscitation risk of pulmonary oedema

›Medication considerations

›Beta-blocker tolerance

›Orthostatic hypotension risk

›Heart rate response may be blunted

›Lower starting doses and cautious titration

›Renal function decline

›Hepatorenal syndrome risk increased

›Drug dosing adjustment for reduced GFR

›Increased delirium risk

›Encephalopathy overlay with baseline cognitive impairment

›Sedation minimisation during endoscopy

›Prognosis and goals of care

›Higher in-hospital mortality in frail older adults

›Frailty assessment before aggressive intervention

›Goals of care discussion when TIPS or transplant considered

›Polypharmacy review

›NSAID elimination

›Diuretic adjustment for renal protection

Pediatrics

›Aetiology differences in children

›Extrahepatic portal vein obstruction most common cause in children without cirrhosis

›Portal cavernoma development

›Better long-term prognosis than cirrhotic aetiology

›Biliary atresia as cirrhotic cause

›Post-Kasai portoenterostomy complications

›Transplant evaluation priority

›Cystic fibrosis-related liver disease

›Multilobular cirrhosis pattern

›Paediatric dosing

›Octreotide weight-based dosing

›1 to 2 mcg per kg IV bolus

›1 to 2 mcg per kg per hour infusion

›Titrate to haemostasis

›Ceftriaxone weight-based dosing

›50 to 100 mg per kg IV daily

›Maximum 2 g per day

›Propranolol for prophylaxis

›0.5 to 1 mg per kg per day in divided doses

›Maximum 4 mg per kg per day

›Endoscopy considerations

›Paediatric gastroenterology team required

›Appropriate scope size selection

›General anaesthesia often required

›TIPS feasibility depends on body size

›Minimum weight considerations

›Refer to paediatric hepatology centre

10Background/b74

Epidemiology

›Prevalence and incidence

›Esophageal varices present in approximately 30% at cirrhosis diagnosis

›Increase to up to 90% with severely decompensated disease

›New varices develop at rate of 5 to 8% per year in compensated cirrhosis

›Annual bleeding rate

›Small varices without red signs 5 to 15% per year

›Large varices or red wale marks approximately 15% per year

›Mortality

›6-week mortality from acute variceal haemorrhage 10 to 15% with modern therapy

›Child-Pugh C carries highest mortality

›Rebleeding risk approximately 60% at 1 year without secondary prophylaxis

›Risk population

›Liver cirrhosis is the dominant risk factor

›All aetiologies including alcohol hepatitis C hepatitis B NAFLD

›HVPG >= 12 mmHg required threshold for variceal bleeding

›< 12 mmHg variceal bleeding essentially does not occur

›Non-cirrhotic portal hypertension

›Portal vein thrombosis

›Schistosomiasis in endemic regions

Pathophysiology

›Portal hypertension development

›Increased intrahepatic resistance

›Fibrosis and regenerative nodule compression of sinusoids

›Hepatic stellate cell contraction contributing dynamic component

›Splanchnic vasodilation

›Nitric oxide excess from portal hypertension

›Hyperdynamic circulation state

›Increased portal blood flow amplifying pressure

›Hepatic venous pressure gradient

›HVPG = wedged hepatic venous pressure minus free hepatic venous pressure

›>= 10 mmHg clinically significant portal hypertension

›>= 12 mmHg variceal bleeding threshold

›Variceal formation and rupture

›Portosystemic collateral development

›Coronary vein to oesophageal plexus pathway primary route

›Left gastric vein to azygous system

›Wall tension and rupture

›LaPlace law: tension proportional to radius times pressure

›Large variceal diameter and high HVPG predict rupture

›Red wale marks as rupture predictors

›Dilated intraepithelial microvasculature

›Strongest endoscopic predictor of bleeding

›Acute-on-chronic liver failure

›Variceal bleeding as precipitant of ACLF

›Sepsis triggered by bacteraemia during haemorrhage

›Hepatorenal syndrome development

›ACLF independently increases 28-day mortality

›Organ failure count determines ACLF grade

›ACLF grade 3 mortality > 70% at 28 days

Therapeutic Considerations

›Restrictive transfusion evidence

›Haemoglobin target 70 g/l versus 90 g/l studied in RCT

›Restrictive strategy improved 6-week survival

›Lower portal pressure achieved with restrictive approach

›Class I recommendation

›Overresuscitation harms

›Increases portal pressure directly

›Promotes variceal rebleeding

›Worsens ascites

›Combined pharmacologic and endoscopic approach

›Vasoactive drug plus EVL superior to either alone

›Octreotide reduces blood flow before scope insertion

›Improves endoscopic visualisation

›Reduces early rebleeding rates

›Antibiotic benefit mechanism

›Prevents translocation of gut bacteria

›Reduces SBP risk during hospitalisation

›Reduces vasodilatation from endotoxaemia

›Non-selective beta-blocker mechanism

›Beta-1 blockade reduces cardiac output

›Decreases splanchnic blood flow

›Beta-2 blockade allows splanchnic vasoconstriction

›Mesenteric arterial tone increase

›Net effect reduces portal pressure

›HVPG reduction >= 20% from baseline predicts response

›HVPG < 12 mmHg ideal target rarely achieved

11Patient Discharge Instructions/pdi29

copy discharge instructions

›Esophageal varices home care

›Take your beta-blocker medication every day without missing doses

›Do not stop it suddenly without calling your doctor

›Report dizziness, fainting, or very slow pulse

›Absolute alcohol avoidance

›Single most important action to slow liver disease progression

›Avoid ibuprofen, naproxen, aspirin, and all NSAIDs

›Increases risk of stomach bleeding and kidney injury

›Low-sodium diet less than 2 g per day if you have fluid retention

›Return to ER immediately for

›Vomiting blood or material that looks like coffee grounds

›Call 911 or go by ambulance

›Black tarry or very dark stools

›Dizziness or fainting

›Sudden severe abdominal pain

›Confusion, unusual sleepiness, or difficult to rouse

›Fever above 38.5 degrees Celsius with your liver condition

›Rapid increase in abdominal swelling

›Follow-up appointments

›Gastroenterology or hepatology within 1 to 2 weeks of discharge

›Repeat band ligation procedure scheduled every 2 to 4 weeks until cleared

›Blood work as directed

›Liver function and kidney function testing

›Liver cancer screening ultrasound every 6 months

›Lifestyle and recovery

›Adequate protein intake 1.2 to 1.5 g per kg body weight per day

›Important to maintain muscle mass with liver disease

12References/r34

Guidelines and key sources

›Society guidelines

›AASLD Practice Guidance on Risk Stratification and Management of Portal Hypertension and Varices in Cirrhosis 2024

›Kaplan DE et al Hepatology 2024

›Comprehensive management framework including carvedilol and TIPS recommendations

›Baveno VII Consensus 2022

›De Franchis R et al Journal of Hepatology 2022

›NSBB and EVL primary prophylaxis recommendations

›Pre-emptive TIPS criteria updated

›American Society for Gastrointestinal Endoscopy guideline 2014

›Hwang JH et al Gastrointestinal Endoscopy 2014

›EVL as first-line endoscopic therapy

›Key clinical trials and systematic reviews

›Cochrane review on band ligation versus no intervention for primary prevention

›Vadera S et al Cochrane Database of Systematic Reviews 2019

›EVL efficacy for primary prophylaxis

›Restrictive versus liberal transfusion RCT

›Haemoglobin 70 g/l target improves survival in variceal bleeding

›Class I recommendation basis

›Early TIPS versus pharmacologic plus endoscopic therapy RCT

›Pre-emptive TIPS 1-year survival 86% vs 61%

›High-risk population Child-Pugh B active bleed or Child-Pugh C

›Background and epidemiology references

›Tapper EB and Parikh ND JAMA 2023

›Diagnosis and Management of Cirrhosis and Its Complications

›Arroyo V et al NEJM 2020

›Acute-on-Chronic Liver Failure

›Singh S et al World Journal of Gastroenterology 2024

Evidence & Review