What is the initial workup for a patient presenting with a variceal bleed?

Workup for Variceal Bleeding

Begin immediate vasoactive drug therapy (terlipressin, somatostatin, or octreotide) and prophylactic antibiotics as soon as variceal bleeding is suspected—even before diagnostic endoscopy—followed by urgent upper endoscopy within 12 hours once hemodynamically stable. 1, 2

Immediate Initial Management (Before Endoscopy)

Hemodynamic Assessment and Resuscitation

• Check vital signs immediately including heart rate, blood pressure, and assess for signs of hypovolemia or shock 1, 2
• Establish at least two large-bore IV catheters (16-gauge or larger) for rapid volume replacement 1, 2
• Begin crystalloid infusion to restore hemodynamic stability, targeting mean arterial pressure >65 mmHg while avoiding fluid overload 1, 2
• Use restrictive transfusion strategy with hemoglobin threshold of 7 g/dL and target range of 7-9 g/dL after transfusion 1

Laboratory Studies

• Obtain complete blood count to determine hemoglobin and hematocrit 1
• Check coagulation parameters including prothrombin time and platelet count 1, 2
• Measure blood urea nitrogen, creatinine, and serum electrolytes 1
• Perform blood typing and cross-matching (6 units) if severe bleeding or hemodynamic instability present 1, 2

Pharmacological Therapy (Start Immediately)

Vasoactive Drugs - Initiate as soon as variceal bleeding is suspected, before endoscopy:

• Terlipressin: 2 mg IV every 4 hours for first 48 hours, then 1 mg IV every 4-6 hours 1
• Somatostatin: 250 µg IV bolus, then 250 µg/hour continuous infusion 1
• Octreotide: 50 µg IV bolus, then 50 µg/hour continuous infusion 1
• Continue vasoactive therapy for 3-5 days to prevent early rebleeding 1, 2

Antibiotic Prophylaxis - Start immediately on presentation:

• Ceftriaxone 1 g IV every 24 hours is first choice in patients with decompensated cirrhosis, those already on quinolone prophylaxis, or in settings with high quinolone resistance 1, 2
• Norfloxacin is an alternative in other settings 1
• Continue for up to 7 days 1

Diagnostic Endoscopy

Timing and Preparation

• Perform upper endoscopy within 12 hours after admission once hemodynamic stability is achieved 1, 2
• Consider pre-endoscopy erythromycin (250 mg IV, 30-120 minutes before) to facilitate the procedure by improving gastric emptying 2
• Ensure adequate bowel preparation if lower endoscopy is needed 3

Endoscopic Findings and Therapy

• Endoscopic variceal band ligation (EVL) is the treatment of choice for esophageal variceal bleeding 1, 2
• Endoscopic injection sclerotherapy is no longer recommended as standard treatment due to higher treatment failure rates and adverse events compared to EVL 1
• For gastric varices, consider cyanoacrylate injection if accessible 4

Risk Stratification

High-Risk Features Requiring Intensive Management

• Child-Pugh Class C <14 points with active bleeding at endoscopy 5
• Child-Pugh Class B with active bleeding at endoscopy 5
• Hemodynamic instability despite initial resuscitation 2
• Severe or refractory ascites 1

Management of Treatment Failure

Definition of Treatment Failure

• Bleeding continues or significant bleeding recurs within 48 hours despite standard therapy 4, 5
• This occurs in approximately 10-20% of patients 1, 5

Rescue Therapy

• TIPS (transjugular intrahepatic portosystemic shunt) is the rescue therapy of choice for persistent bleeding or early rebleeding despite standard therapy 1, 2, 4
• Consider early TIPS (within 72 hours) in high-risk patients (Child B with active bleeding or Child C <14 points) as this markedly decreases rebleeding and improves survival 5
• Balloon tamponade (Sengstaken-Blakemore tube) may be used as a temporary bridge to TIPS if bleeding is difficult to control and TIPS is not immediately available, but use for maximum 24 hours only 2, 5

Special Considerations

Medications to Avoid

• Temporarily suspend non-selective beta-blockers during acute bleeding episode 1
• Avoid nephrotoxic drugs (aminoglycosides, NSAIDs) during acute variceal bleeding 2
• Avoid high doses of beta-blockers and carvedilol 1

Multidisciplinary Approach

• Involve hepatology specialist team early for optimal management of portal hypertension and comorbid conditions 1, 6
• Consider intensive care unit admission for close monitoring in severe cases 1

Common Pitfalls to Avoid

• Do not delay vasoactive drug therapy while waiting for endoscopy—start immediately when variceal bleeding is suspected 2, 7
• Do not over-transfuse—maintain restrictive strategy as over-transfusion may increase portal pressure and worsen bleeding 1, 6
• Do not use starch for volume replacement 2
• Do not delay TIPS placement in high-risk patients or treatment failures—early intervention improves outcomes 5
• Do not continue beta-blockers during acute bleeding—temporarily discontinue and reinstate after recovery 1