Approach to the Critical Patient

Immediate priorities

Airway and breathing threats

Circulation and hemorrhagic shock

Key early resuscitation steps

Monitoring and targets

Hemodynamic monitoring bundle

Escalation triggers

Immediate consults

Consultation triggers

History

Presentation pattern

Core presenting symptoms

Bleeding context

Temporal history

Liver disease history

Known or suspected cirrhosis

Risk factors

Bleeding risk factors

Medication and substance history

Medications affecting bleeding and liver

Symptoms of complications

Hepatic encephalopathy symptoms

Signs of decompensation

Physical Exam

Vital signs and hemodynamic assessment

Hemodynamic status

Stigmata of chronic liver disease

Cutaneous findings (specificity > 90% for cirrhosis)

Alcohol-specific findings

Abdominal examination

Ascites assessment

Organ size

Caput medusae

Neurological examination

Hepatic encephalopathy assessment

Rectal examination

Stool characteristics

Differential Diagnosis

Portal hypertensive sources

Esophageal variceal hemorrhage (ICD-10: I85.01)

Gastric variceal hemorrhage (ICD-10: I86.4)

Portal hypertensive gastropathy (ICD-10: K31.89)

Ectopic varices

Non-variceal UGIB sources

Peptic ulcer disease (ICD-10: K27.0)

Mallory-Weiss tear (ICD-10: K22.6)

Dieulafoy lesion (ICD-10: K31.82)

Gastric malignancy (ICD-10: C16)

Aortoenteric fistula (ICD-10: K28.2)

Systemic mimics

Coagulopathy without structural lesion

Hemobilia

Laboratory Tests

Blood counts and type and screen

Complete blood count

Type and crossmatch

Metabolic and liver panel

Basic metabolic panel

Liver function tests

Coagulation studies

PT/INR

Fibrinogen

Thromboelastography (TEG) or rotational thromboelastometry (ROTEM)

Additional diagnostics

Lactate

Ammonia

Blood cultures

12-lead ECG and troponin

Diagnostic Tests

Scoring Systems

MELD score (Model for End-Stage Liver Disease)

Child-Pugh score

Glasgow Blatchford Score (GBS)

Preemptive TIPS eligibility criteria

MRI

Liver MRI applications

CT

CT angiography abdomen/pelvis

CT liver for complication assessment

Ultrasound

Bedside emergency ultrasound

Doppler ultrasound of portal system

Noninvasive liver stiffness by elastography

Disposition

ICU admission

Criteria for ICU-level care

General ward admission

Criteria for monitored ward

Transfer criteria

Transfer indications

Discharge criteria

Safe discharge checklist

Treatment

Vasoactive therapy

Octreotide (somatostatin analogue)

Terlipressin (vasopressin analogue)

Vasopressin (avoid)

Antibiotic prophylaxis

Ceftriaxone (preferred)

Norfloxacin (alternative)

Endoscopic treatment

Esophagogastroduodenoscopy (EGD)

Endoscopic variceal ligation (EVL)

Cyanoacrylate glue injection

Sclerotherapy

Bridge to definitive therapy

Sengstaken-Blakemore tube (balloon tamponade)

Self-expandable metal stent (SEMS)

TIPS (transjugular intrahepatic portosystemic shunt)

Indications and timing

Contraindications

Secondary prophylaxis

Non-selective beta-blockers (NSBB)

Proton pump inhibitor

Transfusion strategy

Red blood cell transfusion

Fresh frozen plasma

Platelet transfusion

Cryoprecipitate

Special Populations

Pregnancy

Pregnancy-specific considerations

Geriatric

Age-related considerations

Pediatrics

Pediatric variceal bleeding considerations

Background

Epidemiology

Prevalence and incidence

Pathophysiology

Portal hypertension development

Variceal formation and rupture

Therapeutic Considerations

Endoscopy timing evidence

Restrictive transfusion strategy evidence

Antibiotic prophylaxis evidence

Preemptive TIPS evidence

Patient Discharge Instructions

copy discharge instructions

Diagnosis and what happened

Medications

Diet and lifestyle

Follow-up appointments

Return to emergency department immediately if

References

Guidelines and key sources

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

AGA Clinical Practice Update on the Use of Vasoactive Drugs and Intravenous Albumin in Cirrhosis: Expert Review

Diagnosis and Management of Cirrhosis and Its Complications: A Review

Landmark trials and prognostic tools

Restrictive vs. liberal transfusion strategy in acute GI bleeding

Preemptive TIPS in high-risk variceal bleeding

MELD-based model for acute variceal bleeding mortality

MELD 3.0 vs. Child Score in variceal hemorrhage outcomes

Additional clinical references

Management of Acute Upper Gastrointestinal Bleeding

Emergency Medicine Updates: Upper Gastrointestinal Bleeding

Portal vein ultrasound for variceal UGIB prediction in ED

AASLD Practice Guideline on Noninvasive Liver Disease Assessment of Portal Hypertension

CT criteria for clinically significant portal hypertension

Myocardial injury in variceal bleeding and 6-week mortality

Clinical algorithms for prevention of variceal rebleeding