In cirrhotic patients presenting with acute upper gastrointestinal bleeding from portal hypertension, first-line management controls haemorrhage in most cases. This protocol addresses the subset in whom that initial approach did not achieve bleeding control — a situation that demands a defined escalation strategy.
Acute variceal haemorrhage with portal hypertension complicating liver cirrhosis. Acute variceal haemorrhage must be suspected in any cirrhotic patient presenting with upper acute gastrointestinal bleeding; treatment should be started as soon as bleeding is clinically confirmed, regardless of endoscopic confirmation.
First-line management of acute variceal haemorrhage — combining volume replacement, vasoactive drug therapy, antibiotic prophylaxis, and early endoscopic variceal band ligation — achieves bleeding control in approximately 85% of cases.
This protocol applies to the remaining patients in whom bleeding control was not achieved with that initial approach, and a structured rescue strategy is required.
The escalation protocol centres on a rescue interventional approach, with defined temporary bridging options available for situations of massive uncontrolled haemorrhage — including both mechanical and alternative endoscopic options. The protocol also addresses optimisation of ongoing vasoactive therapy and includes measures directed at preventing hepatic encephalopathy. The complete selection criteria, sequence, and full regimen are in the structured protocol.
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.
TIPS should be used as the rescue therapy of choice in such cases (I;1).
Balloon tamponade should be used in case of uncontrolled bleeding, but with pre-requisite of expertise and as a temporary "bridge" until definitive treatment can be instituted and for a maximum of 24 h (III;1).
Removable, covered and self-expanding oesophageal stents can be used as alternative to balloon tamponade (I;2).
When TIPS is not feasible or in case of modest rebleeding, a second endoscopic therapy may be attempted while vasoactive drugs can also be optimised, by doubling the dose of somatostatin and/or changing to terlipressin if not used previously.
In the context of bleeding, where encephalopathy is commonly encountered, prophylactic lactulose may be used to prevent encephalopathy, but further studies are needed (I;2).
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