GI bleeding and abdominal emergencies

Acute variceal bleeding

Reviewed Nov 2026·3 references
New· views rounded down, updated weekly

Baveno VII bundle: restrictive transfusion, vasoactive drug, antibiotics, endoscopy within 12 h, pre-emptive TIPS, and rescue options.

Definition
Suspect variceal bleeding in any patient with cirrhosis or portal hypertension and UGIB. Mortality 10-20% at 6 weeks; highest in Child-Pugh C and with ACLF.

At the bedside

Timed steps
  1. 1

    Resuscitate and protect airway

    0 min

    Two large-bore IVs, cautious volume replacement; intubate for massive haematemesis, encephalopathy (GCS ≤ 8) or before endoscopy if airway at risk.

  2. 2

    Restrictive transfusion

    Transfuse PRBC at Hb ≤ 7 g/dL, target 7-8 g/dL (higher if active cardiovascular disease or massive bleeding). Do not correct INR with FFP; platelets/fibrinogen per clinical judgement.

  3. 3

    Vasoactive drug immediately

    ASAP

    Terlipressin 2 mg IV q4h (or octreotide 50 mcg bolus + 50 mcg/h) as soon as variceal bleed suspected, before endoscopy; continue 2-5 days.

  4. 4

    Antibiotic prophylaxis

    ASAP

    Ceftriaxone 1 g/day IV for up to 7 days (reduces infection, rebleeding and death).

  5. 5

    Endoscopy within 12 h

    ≤ 12 h

    After resuscitation; erythromycin 250 mg IV 30-120 min before improves visibility. Band ligation for oesophageal varices; cyanoacrylate glue for gastric (GOV2/IGV1) varices.

  6. 6

    Pre-emptive TIPS

    ≤ 72 h

    Child-Pugh C 10-13 or Child B > 7 with active bleeding at endoscopy: pre-emptive TIPS within 72 h (ideally < 24 h) if available.

  7. 7

    Refractory bleeding

    Balloon tamponade (Sengstaken-Blakemore/Minnesota, max 24 h) or self-expanding oesophageal stent as bridge to rescue TIPS.

  8. 8

    Prevent complications

    Lactulose/rifaximin to prevent encephalopathy, avoid nephrotoxins, start non-selective beta-blocker after vasoactive drugs stop (secondary prophylaxis) with repeat EVL.

Vasoactive first line

Terlipressin

IV bolus
Dose
2 mg q4h for 48 h, then 1 mg q4h; total 2-5 days
Worked example
Start 2 mg IV immediately; reduce to 1 mg q4h once bleeding controlled

Vasoactive alternative

Octreotide

IV
Dose
50 mcg bolus, then 50 mcg/h
Preparation
500 mcg in 50 mL NS = 10 mcg/mL
Worked example
50 mcg/h = 5 mL/h
Open infusion calculator

Antibiotic prophylaxis

Ceftriaxone

IV
Dose
1 g once daily up to 7 days

Pre-endoscopy prokinetic

Erythromycin

IV
Dose
250 mg over 30 min, 30-120 min before endoscopy
Red flag · call your senior now
Haematemesis with encephalopathy or haemodynamic instability: intubate before endoscopy to prevent aspiration.
Red flag
Rebleeding within 5 days or failure to control: rescue TIPS or balloon tamponade/stent.
Pitfall
Over-transfusion to Hb > 9-10 g/dL raises portal pressure and rebleeding.
Pitfall
Giving FFP to correct INR before endoscopy: INR does not reflect bleeding risk in cirrhosis and FFP raises portal pressure.
Pearl
Start terlipressin and antibiotics in the ED; do not wait for endoscopy.

Calculators for this topic

Infusion rate from a fixed hourly or per-minute dose

Pump rate for non-weight-based infusions such as vasopressin (U/min), labetalol (mg/min) or amiodarone (mg/h).

References

  1. 1

    de Franchis R, Bosch J, Garcia-Tsao G, et al. Baveno VII - Renewing consensus in portal hypertension. J Hepatol 2022;76:959-74.

  2. 2

    Gralnek IM, Stanley AJ, Morris AJ, et al. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): ESGE Guideline - Update 2021. Endoscopy 2021;53:300-32.

  3. 3

    Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med 2013;368:11-21.

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Non-variceal UGIB and Glasgow-Blatchford

Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.