Management of Variceal Bleeding

Initial Resuscitation and Stabilization

The American Association for the Study of Liver Diseases recommends beginning vasoactive therapy immediately upon suspicion of variceal bleeding, even before diagnostic endoscopy is performed, as it facilitates endoscopy, improves early hemostasis, and reduces 5-day rebleeding rates 1, 3
Target hemoglobin of 7-8 g/dL using a restrictive transfusion strategy should be aimed for in fluid resuscitation 2
Vasoactive drugs such as terlipressin, somatostatin, or octreotide should be started as soon as variceal bleeding is suspected and continued for 3-5 days, with terlipressin being the preferred agent due to its proven mortality benefit 1, 2, 4

The American Association for the Study of Liver Diseases recommends administering prophylactic antibiotics immediately, as this improves survival and reduces infection rates, with norfloxacin 400 mg PO twice daily for 7 days being a standard regimen 1, 2, 4, 7
In cases of advanced cirrhosis, IV ceftriaxone 1 g daily is superior to norfloxacin, particularly in centers with quinolone-resistant organisms 1, 2, 4, 7

Upper endoscopy should be performed within 12 hours once the patient is hemodynamically stable, with endoscopic variceal ligation being the treatment of choice for esophageal varices, achieving 85-90% initial hemostasis rates 1, 2, 3, 5, 6
Combination therapy of endoscopic variceal ligation plus vasoactive drugs for 2 days reduces very early rebleeding and treatment failure compared to vasoactive drugs alone for 5 days 5, 6

Transjugular intrahepatic portosystemic shunt with covered stents is the first-line rescue therapy for refractory bleeding, with early TIPS strategy in high-risk patients decreasing rebleeding and improving survival 2, 6

Beta-blockers should not be used acutely in variceal bleeding as they decrease blood pressure and blunt compensatory tachycardia 4, 7
Tranexamic acid and recombinant factor VIIa should not be used due to lack of benefit and potential increased thromboembolic risk 3, 8
Routine correction of coagulopathy is not indicated if hemostasis is achieved with standard therapy 3, 8