A 52-year-old man with known cirrhosis secondary to hepatitis B presents to the emergency department with haematemesis and melaena. On examination, blood pressure is 95/60 mmHg, heart rate 118/min, and he appears icteric. Upper endoscopy reveals large oesophageal varices with active bleeding. After fluid resuscitation and blood transfusion, he receives terlipressin and antibiotics. Which of the following is the most appropriate next step in management?

Explanation

## Management of Acute Variceal Bleeding in Cirrhosis ### Immediate Approach **Key Point:** Acute variceal bleeding is a medical emergency with mortality of 15–20% if untreated. The treatment algorithm combines pharmacological and endoscopic strategies. ### Pharmacological Therapy 1. **Vasoactive agents** — initiated immediately, even before endoscopy: - Terlipressin (preferred in India) — splanchnic vasoconstrictor, reduces portal pressure - Octreotide — alternative, continuous infusion - Continue for 2–5 days 2. **Antibiotics** — reduce bacterial translocation and rebleeding: - Ceftriaxone 1 g IV 12-hourly (preferred) - Norfloxacin 400 mg BD (if allergy) - Duration: 7 days ### Endoscopic Therapy — The Gold Standard **High-Yield:** Endoscopic variceal ligation (EVL) is superior to sclerotherapy for oesophageal varices: - Lower rebleeding rates (18% vs 48% with sclerotherapy) - Lower mortality (6% vs 11%) - Fewer complications (strictures, perforation) - Should be performed **within 12 hours** of presentation ### Why This Patient Needs EVL Now This patient has: - Active variceal bleeding (haematemesis + melaena) - Haemodynamic instability (BP 95/60, HR 118) - Large varices on endoscopy **Clinical Pearl:** EVL is the definitive haemostatic intervention. It should not be delayed — performing it within 12 hours improves outcomes and reduces rebleeding. ### Secondary Prophylaxis After successful EVL, the patient requires: - **Beta-blockers** (propranolol, carvedilol) — reduce portal pressure by 20–25% - **Repeat EVL sessions** — every 2–4 weeks until variceal eradication - **TIPS** — reserved for: - Failure of EVL + pharmacotherapy (rebleeding despite 2 EVL sessions) - Gastric varices - Refractory ascites ```mermaid flowchart TD A[Acute variceal bleeding]:::outcome --> B[Fluid resuscitation + RBC transfusion]:::action B --> C[Start terlipressin + antibiotics]:::action C --> D[Urgent upper endoscopy]:::action D --> E{Varix type?}:::decision E -->|Oesophageal| F[EVL within 12 hours]:::action E -->|Gastric| G[Cyanoacrylate injection ± EVL]:::action F --> H{Haemostasis achieved?}:::decision H -->|Yes| I[Secondary prophylaxis: beta-blocker + repeat EVL]:::action H -->|No| J[Rescue TIPS]:::urgent ``` **Mnemonic:** **VASE** — Vasoactive agents, Antibiotics, Sclerotherapy/EVL, Endoscopy (in order of initiation). ### Why Not the Other Options? - **Repeat endoscopy after 48 hours:** Delays definitive haemostasis; increases risk of rebleeding and death. - **Urgent TIPS:** Reserved for failure of EVL + pharmacotherapy, not first-line. TIPS carries risk of hepatic encephalopathy. - **Propranolol alone:** Secondary prophylaxis only; does not stop active bleeding. [cite:Harrison 21e Ch 297]