Clinical Commander

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gi.variceal_bleed.v1

Acute variceal hemorrhage (esophageal / gastric / ectopic)

gastroenterologyacuteadultacuteinpatienttransition
Start encounter →Print handoutPRODUCTION

Variceal hemorrhage bundle — restrictive transfusion (Hgb ≥7), octreotide 50 mcg bolus + 50 mcg/h × 3–5 d, ceftriaxone 1 g IV daily × 5–7 d, EGD ≤12 h. Early TIPS within 72 h for Child-Pugh B with active bleed at EGD or Child-Pugh C ≤14 (Garcia-Pagan). Secondary prophylaxis: NSBB (carvedilol preferred) + serial EVL until variceal obliteration. Open: manifest, problem-package, RxCUI verification, variceal-specific risk + TIPS calculators absent, tests.

Entry points (5)

  • symptom
    Hematemesis (red or coffee-ground) (Baveno VII de Franchis 2022)
    hematemesis
  • symptom
    Melena or hematochezia in cirrhotic patient (Baveno VII 2022; AASLD 2023)
    melena_or_hematochezia
  • symptom
    Syncope or hypotension in cirrhotic patient (Baveno VII 2022 acute bleed criteria)
    syncope_or_hypotension
  • history
    Cirrhosis with known varices presenting with bleeding (Baveno VII 2022; AASLD 2023)
    cirrhosis_with_known_varices
  • history
    Non-cirrhotic portal hypertension — e.g., schistosomiasis, PVT (Baveno VII 2022 Section non-cirrhotic PHT)
    portal_htn_non_cirrhotic

Required inputs (19)

  • agerequired
    demographic • used at CONTEXT
    Risk stratification (Baveno VII 2022; AASLD 2023)
  • sbprequired
    vital • used at RED_FLAGS
    Hemodynamic instability triggers transfusion + ICU (Baveno VII 2022 resuscitation)
  • hrrequired
    vital • used at CONTEXT
    Tachycardia indicates volume depletion (Baveno VII 2022)
  • spo2required
    vital • used at RED_FLAGS
    Aspiration / hypoxemia (Baveno VII 2022 airway management)
  • cbc_with_hgbrequired
    lab • used at INITIAL_WORKUP
    Restrictive transfusion threshold Hgb >=7 (Villanueva NEJM 2013 PMID 23281973; Baveno VII 2022)
  • type_and_screenrequired
    lab • used at INITIAL_WORKUP
    Pre-transfusion (Baveno VII 2022; AASLD 2023)
  • coags_pt_inr_aptt_fibrinogenrequired
    lab • used at INITIAL_WORKUP
    Targeted correction without over-correction (Baveno VII 2022; EASL 2018)
  • cmprequired
    lab • used at INITIAL_WORKUP
    AKI common; baseline electrolytes (Baveno VII 2022; AASLD 2023)
  • lftrequired
    lab • used at INITIAL_WORKUP
    Cirrhosis baseline + HE risk (AASLD 2023; Baveno VII 2022 Child-Pugh)
  • lactaterequired
    lab • used at INITIAL_WORKUP
    Severity (Baveno VII 2022)
  • ammonia_if_he_concerns
    lab • used at BRANCHING_WORKUP
    Encephalopathy assessment (AASLD 2023 HE; EASL 2018)
  • cxrrequired
    imaging • used at INITIAL_WORKUP
    Aspiration / pneumonia / mediastinum (Baveno VII 2022)
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    Demand ischemia in shock (Baveno VII 2022)
  • bedside_us_ascites
    imaging • used at INITIAL_WORKUP
    Ascites assessment + paracentesis if SBP suspected (AASLD 2023; Baveno VII 2022)
  • egdrequired
    imaging • used at TREATMENT
    Therapeutic + diagnostic; band ligation / glue / TIPS guidance; EGD <=12 h (Baveno VII 2022 de Franchis PMID 35120736; AASLD 2023)
  • cta_for_ectopic_or_active
    imaging • used at BRANCHING_WORKUP
    CT-A if EGD non-diagnostic / ectopic suspicion (ACG 2021; Baveno VII 2022)
  • cirrhosis_etiology_meld_childrequired
    history • used at CONTEXT
    Risk stratification + TIPS candidacy (Baveno VII 2022; Garcia-Pagan NEJM 2010 early TIPS criteria)
  • prior_bleed_or_NSBB_userequired
    history • used at CONTEXT
    Recurrent vs first bleed; NSBB dose (Baveno VII 2022 secondary prophylaxis)
  • current_medsrequired
    medication • used at CONTEXT
    AC / antiplatelet — reverse if needed (Baveno VII 2022; EASL 2018)

12-phase flow (12)

  1. 1FRAME
    Confirm variceal source via EGD; differentiate from non-variceal UGIB; identify high-risk features (Baveno VII 2022 de Franchis; AASLD 2023)
    inputs: egd
    advance: Source identified
  2. 2ENTRY
    Hematemesis / melena / hematochezia / syncope in cirrhotic / portal HTN (Baveno VII 2022)
    inputs: age
    advance: Engine entered
  3. 3CONTEXT
    Cirrhosis stage — MELD-Na, Child-Pugh; prior bleed; NSBB use; AC / antiplatelet; alcohol; HE; OAC reversal needs (Baveno VII 2022; AASLD 2023; Garcia-Pagan NEJM 2010 TIPS criteria)
    inputs: cirrhosis_etiology_meld_child, prior_bleed_or_NSBB_use, current_meds
    advance: Context complete
  4. 4RED_FLAGS
    Hemodynamic instability, massive bleed, AMS / airway compromise (Baveno VII 2022 acute management; AASLD 2023)
    inputs: sbp, spo2
    actions: ugib
    advance: Stabilised or escalated
  5. 5INITIAL_WORKUP
    CBC, type-screen, coags + fibrinogen, CMP, LFT, lactate, ECG, CXR, bedside US ascites; ammonia if HE (Baveno VII 2022; AASLD 2023)
    inputs: cbc_with_hgb, type_and_screen, coags_pt_inr_aptt_fibrinogen, cmp, lft, lactate, cxr, ecg
    actions: panel.cbc, panel.lft, panel.coag, panel.renal
    advance: Stage-1 returned
  6. 6BRANCHING_WORKUP
    EGD therapeutic; CT-A if non-diagnostic (ACG 2021); balloon tamponade as bridge <=24 h; paracentesis if SBP suspected; AC reversal as needed (Baveno VII 2022; EASL 2018)
    inputs: egd, cta_for_ectopic_or_active
    advance: Source localised + treated
  7. 7DIFFERENTIAL
    Esophageal vs gastric vs ectopic varices vs PHT gastropathy vs non-variceal — PUD, Mallory-Weiss, malignancy (Baveno VII 2022; ACG 2021)
    advance: Source confirmed
  8. 8RISK_STRATIFICATION
    MELD-Na, Child-Pugh, AIMS65; high-risk if Child-Pugh B with active bleed at EGD or Child-Pugh C → early TIPS (Garcia-Pagan NEJM 2010 PMID 20573925; Baveno VII 2022)
    actions: calc.meld_na, calc.aims65, calc.glasgow_blatchford
    advance: Tier documented
  9. 9TREATMENT
    Resuscitate — restrictive transfusion Hgb >=7 (Villanueva NEJM 2013); octreotide 50 mcg bolus + 50 mcg/h x 3-5 d; ceftriaxone 1 g IV daily x 5-7 d (Baveno VII 2022; AASLD 2023); EGD <=12 h with band ligation (esophageal) or cyanoacrylate (gastric); TIPS <=72 h for high-risk Child-Pugh B/C (Garcia-Pagan NEJM 2010); balloon tamponade bridge <=24 h; AC reversal targeted; PPI; secondary prophylaxis NSBB + serial EVL (Baveno VII 2022)
    inputs: cbc_with_hgb, coags_pt_inr_aptt_fibrinogen, egd
    advance: Plan documented
  10. 10DISPOSITION
    ICU for active bleed / unstable; ward when stable + post-EGD (Baveno VII 2022; AASLD 2023)
    advance: Disposition documented
  11. 11MONITORING
    Hgb q6h initially, vitals q1h, ammonia, encephalopathy, infection signs, AC plan (Baveno VII 2022; AASLD 2023)
    inputs: cbc_with_hgb
    advance: Monitoring documented
  12. 12FOLLOWUP
    Hepatology q1-3 mo; serial EVL until obliteration; transplant evaluation; HE management (Baveno VII 2022 secondary prophylaxis; AASLD 2023)
    advance: Follow-up booked