Esophageal Variceal Bleeding — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Bleeding controlled by endoscopy?
   After the initial bundle — is bleeding controlled by endoscopy? (A lethal complication of portal hypertension/cirrhosis, 6-week mortality 10–20%. Initial bundle (start on arrival): airway protection (aspiration risk; intubate for massive bleeding/altered consciousness), two large-bore IV lines, cross-match; restrictive transfusion (transfuse only at Hb <7, target 7–8) — over-transfusion raises portal pressure; vasoactive drug on arrival, before endoscopy — terlipressin/octreotide/somatostatin for 3–5 days; prophylactic antibiotics for all cirrhotics with GI bleeding (ceftriaxone 1 g/day, up to 7 days); correct severe coagulopathy, PPI. Endoscopy within 12 h.)
   • Endoscopic hemostasis successful → Endoscopic hemostasis successful
   • Endoscopy-refractory / uncontrolled massive bleed → Refractory → tamponade tube / TIPS
2. [End] Endoscopic hemostasis successful
   Successful esophageal band ligation / gastric variceal tissue-adhesive: continue the vasoactive drug 3–5 days (may stop at 24–48 h in selected cases) + antibiotics up to 7 days; lactulose/rifaximin to prevent hepatic encephalopathy; monitor for rebleeding. Secondary prevention: non-selective beta-blocker + repeat banding until eradication.
3. [End] Refractory → tamponade tube / TIPS
   Endoscopy-refractory / uncontrolled massive bleed: balloon tamponade tube (Sengstaken-Blakemore) for temporary compression as a bridge (≤24 h, with airway protection); TIPS as soon as possible (consider early TIPS within 72 h for high-risk Child-Pugh B with active bleeding / Child C); gastric varices may have BRTO; maintain the vasoactive drug and antibiotics, resuscitate aggressively and correct coagulopathy.

Source guidelines & references

• ESGE guideline on esophagogastric variceal bleeding; APASL/AASLD acute variceal hemorrhage

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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