Liver cirrhosis
ICD-10 K74 · ICD-11 DB93.1

Treatment of Liver Cirrhosis in Acute Variceal Haemorrhage

Acute variceal haemorrhage is a life-threatening emergency in patients with liver cirrhosis. In any cirrhotic patient presenting with acute upper gastrointestinal bleeding, variceal haemorrhage must be suspected and treatment initiated immediately upon clinical confirmation — without waiting for endoscopic verification.

Clinical Scenario

This protocol addresses cirrhotic patients with acute variceal haemorrhage or acute upper gastrointestinal bleeding in the setting of portal hypertension. Rapid recognition and a structured multi-component response are essential to outcomes in this scenario.

Management Approach

Initial management combines prompt haemodynamic stabilisation — using volume replacement guided by a restrictive transfusion strategy — with early vasoactive drug therapy initiated before endoscopy, alongside urgent endoscopic assessment and intervention as a central component of haemostasis.

The complete regimen — including antibiotic prophylaxis, pre-endoscopy preparation, specific drug selection and sequencing, and criteria for advanced interventional options — is available in the full protocol.

Treatment Goal

The primary aim is control of bleeding, achievable in the majority of cases with structured first-line management.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1016/j.jhep.2018.03.024

Acute variceal haemorrhage (AVH) must be suspected in any cirrhotic patient presenting with upper acute GI bleeding and treatment should be started as soon as bleeding is clinically confirmed, regardless the lack of confirmation by upper endoscopy.

Volume replacement should be initiated promptly to restore and maintain haemodynamic stability (III;1).

A restrictive transfusion strategy is recommended in most patients with a haemoglobin threshold for transfusion of 7 g/dl and a target range of 7–9 g/dl (I;1).

Vasoactive drug therapy should be initiated as soon as acute variceal bleeding is suspected, and before endoscopy. Terlipressin, somatostatin or octreotide are accepted options. In patients with acute variceal bleeding drug therapy should be administered for three to five days (I;1).

Gastroscopy should be performed within the first 12 h after admission once haemodynamic stability has been achieved, to ascertain the cause of haemorrhage and to provide endoscopic therapy (II-2;1).

Goals of therapy in AVH include the control of bleeding, as well as the prevention of early recurrence and the prevention of six-week mortality, which is considered the main treatment outcome by consensus.

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