Liver emergencies

Variceal bleeding

Overview and approach

Portal-hypertensive bleeding can be life-threatening and needs a coordinated emergency pathway.

GESA published an Australian consensus on portal hypertension in cirrhosis (Hepatology Communications, 2026) covering variceal bleeding, ascites and hepatic encephalopathy (1).
Majumdar et al., Hepatol Commun 2026;10(4):e0934 – 52 recommendations across 9 domains (3).
Core bundle for suspected variceal bleeding (GESA Figure 2): resuscitate (target MAP >65) → restrictive transfusion → IV terlipressin or octreotide → IV ceftriaxone 1 g daily → endoscopy within 12 h with band ligation → consider pre-emptive TIPS within 72 h in high-risk patients (3).
Primary prevention: in compensated cirrhosis with clinically significant portal hypertension (CSPH), an NSBB (preferably carvedilol) prevents decompensation; if on carvedilol, routine variceal screening endoscopy is not needed (3)(4).
- CSPH ruled out: liver stiffness ≤15 kPa and platelets ≥150 x10⁹/L; ruled in: liver stiffness ≥25 kPa (viral, alcohol, non-obese MASH) (4).

Assessment and clinical features

Assess ABCDE, perfusion, haematemesis/melaena, liver history and antithrombotics.

Haematemesis, melaena, haemodynamic compromise, known cirrhosis or portal hypertension. Decompensated cirrhosis is a medical emergency with in-hospital mortality of 10 to 20%; discuss with gastroenterology or a liver service early (2).
Stigmata of chronic liver disease, ascites, encephalopathy (bleeding is a major precipitant), jaundice.
Risk stratify: Child-Pugh and MELD; these decide pre-emptive TIPS eligibility (Child-Pugh C 10–13, Child-Pugh B 8–9 with active bleeding at endoscopy, or MELD >19 in GESA; Baveno VII uses Child C <14, Child B >7 with active bleeding, or HVPG >20 mmHg) (3)(4).
Airway: protect it (intubate) in massive haematemesis or reduced GCS before endoscopy.

Differentials and investigations

Use blood count, renal/coagulation and blood-bank support without delaying resuscitation.

Other causes of upper GI bleeding (peptic ulcer, portal hypertensive gastropathy) are also possible.
Bloods: FBC, group and crossmatch, INR, fibrinogen, U&E/creatinine, LFTs, lactate, VBG; blood cultures (infection is common and drives rebleeding).
INR and platelets do not reflect bleeding risk in cirrhosis: avoid routine correction with FFP/platelets unless a massive transfusion protocol is activated (3).
Endoscopy within 12 h of presentation after resuscitation (3)(4). Pre-endoscopy erythromycin 250 mg IV 30–120 min before, if no QT prolongation, improves the view (4).
Gastric varices: classify by Sarin (GOV1, GOV2, IGV1, IGV2); cardiofundal varices need cross-sectional imaging of the shunt anatomy after haemostasis (3).

Management and follow-up

Provide urgent GI/endoscopy input with local vasoactive, antibiotic and haemostatic pathway.

GESA consensus (1): early terlipressin or octreotide, ceftriaxone for 3 to 7 days, restrictive transfusion (target 70 to 90 g/L) and endoscopy within 12 hours.
Transfusion: packed red cells if Hb <70 g/L, target 70–90 g/L (GESA, EASL); Baveno VII target 70–80 g/L. Over-transfusion raises portal pressure and rebleeding (3)(4)(5). Massive bleeding: local massive transfusion protocol (3).
Vasoactive drug – start as soon as variceal bleeding is suspected (before endoscopy) and continue 2–5 days (3)(4):
- Terlipressin 2 mg IV every 4 h for the first 48 h, then 1 mg every 4 h (EASL) (5). BSG notes many units reduce to 6-hourly because of peripheral ischaemia (6).
- Octreotide 50 µg IV bolus then 50 µg/h infusion (5).
- Terlipressin: screen for ischaemic heart/peripheral vascular disease (ECG) and monitor sodium (hyponatraemia) (4)(5). Australian terlipressin is dosed as terlipressin acetate.
Antibiotic prophylaxis: ceftriaxone 1 g IV daily, continue until discharge or maximum 7 days (GESA) (3); reduces infection, rebleeding and death (5).
Avoid routine PPIs (infection risk); stop them once variceal bleeding is confirmed (3).
Endoscopic therapy: band ligation for oesophageal varices / GOV1; cyanoacrylate, thrombin or EUS-guided coiling for cardiofundal varices (centre-dependent) (3).
Failure to control bleeding: balloon tamponade or Danis self-expanding oesophageal stent (stent has fewer complications), relook endoscopy (48 h for balloon; stent removal by 7 days), then salvage TIPS; transfer to a TIPS centre once stabilised if needed (3).
Pre-emptive TIPS within 72 h (ideally <24 h) after haemostasis in high-risk patients (criteria above) (3)(4).
Prevent HE: lactulose (oral or enema) to clear blood from the gut (4). Tranexamic acid is not recommended (4).
Anticoagulants: temporarily withhold during acute bleeding (4).
Secondary prophylaxis (no TIPS): start NSBB before discharge (carvedilol preferred) + repeat band ligation every 1–3 months until eradication, endoscopy 6 months later, then annually; TIPS if rebleeding despite this (3)(4).
NSBB doses:
- Carvedilol: target 12.5 mg daily, as 6.25 mg bd or 12.5 mg daily (GESA) (3); BSG: start 6.25 mg daily, increase to 12.5 mg after 1 week if tolerated (6).
- Propranolol: 40 mg bd, titrate to HR 50–55 or maximum tolerated (max 320 mg/day) (6).
- Withhold NSBB with SBP <90 mmHg, Na <130 mmol/L or AKI (3).

Red flags and clinical pearls

Do not over-resuscitate blindly or delay endoscopy planning; airway and transfusion strategy need senior judgement.

Give terlipressin/octreotide and ceftriaxone in ED on suspicion; do not wait for endoscopy (3)(4).
Hb <70 g/L is the trigger, not a target to "fill up" (3).
Variceal bleeding often triggers HE, infection and AKI: give lactulose to clear blood from the gut (4), and consider a diagnostic tap if ascites is present (see Ascites and SBP page).
Child-Pugh C or active bleeding at endoscopy in Child B = think pre-emptive TIPS early (call the liver unit) (3)(4).
No haemostasis at endoscopy despite vasoactive drug + band ligation = go to tamponade/stent and salvage TIPS (3).
Every survivor needs secondary prophylaxis arranged before discharge (3).

References

Last updated from Sen’s notes on 9 October 2026.