Esophageal Variceal Bleeding - Diagnosis and Management Summary

PRE-ENDOSCOPY

Vasoactive agents - Octreotide: 

 • 50mcg bolus → 50mcg/hr infusion

 • Continue for 2-5 days, Can consider stopping 24h after hemostasis

Antibiotics - Ceftriaxone (or equivalent); 

 • 1g IV q24h, Duration = 7 days, Can transition to fluoroquinolone to complete course

Restrictive RBC transfusion threshold:

 • Goal Hgb 7-9 g/dL

PPI infusion - Commonly used adjunct to octreotide when unclear source (in case of PUD)

PERI-ENDOSCOPY

Endoscopic variceal ligation - EGD should be performed within 12 hours of presentation

Transjugular intrahepatic portosystemic shunt (TIPS)

 • Vasoactive agents can be discontinued following TIPS

 • Pre-TIPS evaluation (if feasible): TTE (evaluate R-sided cardiac function), Cross-sectional imaging (anatomy)

POST-ENDOSCOPY

Surveillance EGD ~2 weeks after index procedure and every 2-4 weeks thereafter until eradication achieved

Non-selective ß-blocker:

 • Nadolol 20mg daily

 • Propranolol 10mg BID

 • Carvedilol 3.125mg BID



- Dr. Adam Winters @adam_c_winters



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