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Hepatobiliary SurgeryEmergency

Acute Variceal Hemorrhage Management (Baveno VII 2022)

Acute Variceal Hemorrhage Management (Baveno VII 2022): Acute Variceal Hemorrhage → Initial Resuscitation → Vasoactive Therapy (START IMMEDIATELY) → Pro...

Pathway Overview

14 steps

Algorithm Steps

14 total

  1. 01Start

    Acute Variceal Hemorrhage

    Suspected or confirmed variceal bleeding

  2. 02Warning

    Initial Resuscitation

    SIMULTANEOUS interventions

    • Secure airway (intubate if altered MS/massive)
    • Large bore IV access x 2
    • Type and crossmatch
    • Restrictive transfusion: Target Hgb 7-8 g/dL
    • Avoid over-resuscitation (worsens PHT)
    • Correct coagulopathy if INR >2.5
    • Platelets if <50,000
  3. 03Action

    Vasoactive Therapy (START IMMEDIATELY)

    Before EGD - reduces portal pressure

    • OCTREOTIDE (US first-line):
    • - Bolus: 50 mcg IV
    • - Infusion: 50 mcg/hr x 2-5 days
    • TERLIPRESSIN (if available):
    • - 2 mg IV q4h x 48h, then 1 mg q4h
    • - Contraindicated in CAD, PVD
    • OR SOMATOSTATIN:
    • - Bolus: 250 mcg IV
    • - Infusion: 250-500 mcg/hr
  4. 04Action

    Prophylactic Antibiotics

    Reduces mortality - START IMMEDIATELY

    • CEFTRIAXONE 1g IV q24h (preferred)
    • - For 5-7 days
    • - Reduces rebleeding and mortality
    • - Prevents SBP
    • ALTERNATIVE: Norfloxacin 400mg PO BID
    • (if low-risk, no quinolone resistance)
  5. 05Action

    PPI Therapy

    After banding

    • High-dose PPI after EVL
    • Pantoprazole 40mg IV BID or
    • Omeprazole 40mg IV BID
    • Promotes ulcer healing post-banding
  6. 06Action

    Urgent EGD

    Within 12 hours of presentation

    • Timing: Within 12 hours
    • After hemodynamic stabilization
    • Intubation if: Massive bleed, encephalopathy
    • Erythromycin 250mg IV 30-90 min before
    • (improves visualization)
  7. 07Decision

    Endoscopic Findings

    Type of varices

  8. 08Action

    Esophageal Varices

    Band ligation first-line

    • ENDOSCOPIC VARICEAL LIGATION (EVL)
    • - First-line therapy
    • - Multiple bands at bleeding site
    • - Start distally, move proximally
    • SCLEROTHERAPY:
    • - If EVL not possible
    • - Higher complication rate
  9. 09Decision

    Hemostasis Achieved?

    Assess for rebleeding

  10. 10Warning

    Rescue Therapy

    For refractory bleeding

    • BALLOON TAMPONADE (bridge to TIPS):
    • - Sengstaken-Blakemore or Minnesota tube
    • - Inflate gastric balloon first
    • - Max 24 hours
    • - Intubate before placement
    • SELF-EXPANDING METAL STENT:
    • - Danis/SX-Ella stent
    • - Alternative to balloon
    • Then → TIPS
  11. 11Action

    TIPS (Transjugular Intrahepatic Portosystemic Shunt)

    For refractory/high-risk

    • INDICATIONS:
    • - Refractory to endoscopic therapy
    • - High-risk patients (preemptive TIPS)
    • EARLY/PREEMPTIVE TIPS:
    • - Within 72h (ideally <24h)
    • - For Child-Pugh B with active bleeding
    • - For Child-Pugh C (10-13 points)
    • COVERED STENTS preferred
    • Reduces rebleeding to <15%
  12. 12Action

    Secondary Prophylaxis

    Prevent rebleeding

    • NSBB + EVL combination:
    • - Propranolol: Target HR 55-60
    • - Or Carvedilol 6.25-12.5mg BID
    • - Repeat EVL q2-4 weeks until obliterated
    • If TIPS placed: Annual surveillance
    • Lifelong therapy required
  13. 13Outcome

    Outcomes

    Prognosis

    • 6-week mortality: 15-20%
    • Rebleeding without prophylaxis: 60%
    • Rebleeding with NSBB + EVL: 20-30%
    • TIPS controls bleeding: >90%
    • Consider transplant evaluation
  14. Path rejoins step 12Shared downstream outcome
  15. 14Action

    Gastric Varices

    Cyanoacrylate glue or TIPS

    • GOV1 (extending from EV): EVL may work
    • GOV2/IGV1: Cyanoacrylate injection
    • - 0.5-1 mL per injection
    • - Mixed with lipiodol
    • Consider early TIPS for gastric varices
  16. Path rejoins step 09Shared downstream outcome

Guideline Source

Baveno VII Consensus for Portal Hypertension

DOI: 10.1016/j.jhep.2021.12.003

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Terlipressin availability varies
  • TIPS expertise required
  • Child-Pugh score affects outcomes
  • Requires multidisciplinary approach

Applicable Regions

USEU
Version 1Next review: 2027-01-11

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Frequently Asked Questions

What is the Acute Variceal Hemorrhage Management (Baveno VII 2022)?

The Acute Variceal Hemorrhage Management (Baveno VII 2022) is a emergency clinical algorithm for Hepatobiliary Surgery. It provides a structured decision tree to guide clinical decision-making, based on Baveno VII Consensus for Portal Hypertension.

What guideline is the Acute Variceal Hemorrhage Management (Baveno VII 2022) based on?

This algorithm is based on Baveno VII Consensus for Portal Hypertension (DOI: 10.1016/j.jhep.2021.12.003).

What are the limitations of the Acute Variceal Hemorrhage Management (Baveno VII 2022)?

Known limitations include: Terlipressin availability varies; TIPS expertise required; Child-Pugh score affects outcomes; Requires multidisciplinary approach. Individual patient factors may require deviation from these recommendations.

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