Clinical Commander

Back to dossier
gi.variceal_bleed.v1PRODUCTION
gi.variceal_bleed.v1

Acute variceal hemorrhage (esophageal / gastric / ectopic)

gastroenterologyacuteadult
Hard-required inputs
0 / 16
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm variceal source via EGD; differentiate from non-variceal UGIB; identify high-risk features (Baveno VII 2022 de Franchis; AASLD 2023)

Inputs
1
Actions
0
Advance rule
Set
Advance when

Source identified

Patient inputs (19)

Risk stratification (Baveno VII 2022; AASLD 2023)

Tachycardia indicates volume depletion (Baveno VII 2022)

Risk stratification + TIPS candidacy (Baveno VII 2022; Garcia-Pagan NEJM 2010 early TIPS criteria)

Recurrent vs first bleed; NSBB dose (Baveno VII 2022 secondary prophylaxis)

AC / antiplatelet — reverse if needed (Baveno VII 2022; EASL 2018)

Restrictive transfusion threshold Hgb >=7 (Villanueva NEJM 2013 PMID 23281973; Baveno VII 2022)

Pre-transfusion (Baveno VII 2022; AASLD 2023)

Targeted correction without over-correction (Baveno VII 2022; EASL 2018)

AKI common; baseline electrolytes (Baveno VII 2022; AASLD 2023)

Cirrhosis baseline + HE risk (AASLD 2023; Baveno VII 2022 Child-Pugh)

Severity (Baveno VII 2022)

Aspiration / pneumonia / mediastinum (Baveno VII 2022)

Demand ischemia in shock (Baveno VII 2022)

Hemodynamic instability triggers transfusion + ICU (Baveno VII 2022 resuscitation)

Aspiration / hypoxemia (Baveno VII 2022 airway management)

Therapeutic + diagnostic; band ligation / glue / TIPS guidance; EGD <=12 h (Baveno VII 2022 de Franchis PMID 35120736; AASLD 2023)

Encephalopathy assessment (AASLD 2023 HE; EASL 2018)

CT-A if EGD non-diagnostic / ectopic suspicion (ACG 2021; Baveno VII 2022)

Ascites assessment + paracentesis if SBP suspected (AASLD 2023; Baveno VII 2022)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateningmassive_active_variceal_bleed
    Hematemesis with hypotension or hemoglobin drop ≥2 g/dL
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpersistent_bleed_despite_egd
    Continued bleeding despite band ligation / glue
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehigh_risk_for_early_tips
    Child-Pugh B with active bleed at EGD or Child-Pugh C ≤14 within 72 h of EGD
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresbp_concurrent
    Ascites + fever / abd pain / leukocytosis in cirrhotic with bleed
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereAC_or_antiplatelet_on_board
    Variceal bleed in patient on AC / antiplatelet
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveregastric_varices
    Bleeding gastric varices identified on EGD
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehepatic_encephalopathy_post_bleed
    New AMS / asterixis post bleed
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONrequiredDrives risk stratification
Loading…

Recommended regimen

Acute variceal hemorrhage bundle
axis: variceal_acute_bundle
Selected axis "Acute variceal hemorrhage bundle" by default fallback (first axis)
  • octreotide
    first line
    somatostatin_analog
    50 mcg IV bolus then 50 mcg/h infusion • IV • continuous × 3–5 d
    triggers: suspected_or_confirmed_variceal_bleed
    Reduces splanchnic flow; bridge to EGD (Baveno VII 2022 de Franchis PMID 35120736; AASLD 2023)
    rxcui 7617
  • ceftriaxone
    first line
    cephalosporin_3rd_gen
    1 g IV • IV • daily × 5–7 d
    triggers: cirrhosis_with_GI_bleed
    Reduces SBP and infection mortality (Cochrane; Baveno VII 2022; AASLD 2023; EASL 2018)
    rxcui 2193
  • terlipressin
    second line
    vasopressin_analog
    2 mg IV q4h × 24 h then 1 mg IV q4h • IV • q4h
    triggers: octreotide_unavailable, HRS_AKI_concurrent
    Where available; CONFIRM trial benefit in HRS-AKI; ischemic risk (Baveno VII 2022; EASL 2018)
    rxcui 57048
  • pantoprazole
    add on
    PPI
    80 mg IV bolus then 8 mg/h • IV • continuous × 72 h then PO
    triggers: concurrent_PUD_or_unclear_source
    Acid suppression for PUD if mixed source (ACG 2021 UGIB)
    rxcui 40790
  • lactulose
    add on
    osmotic_laxative
    30–45 mL • PO/PR • q6h titrate
    triggers: HE_with_blood_in_GI_tract
    HE risk after blood meal (AASLD 2023 HE guideline; EASL 2018)
    rxcui 6218
  • rifaximin
    add on
    non_absorbable_antibiotic
    550 mg • PO • BID
    triggers: HE_recurrent
    Adjunct to lactulose for HE prevention (Bass NEJM 2010; AASLD 2023)
    rxcui 35619

ed playbook — drug actions (5)

  1. 1. IV fluid + restrictive transfusion
    crystalloid bolus, PRBC to Hgb 7–8 • IV • titrated
    trigger: Hgb <7 or hemodynamic instability
    Villanueva NEJM 2013 PMID 23281973; Baveno VII 2022
  2. 2. octreotide
    50 mcg IV bolus + 50 mcg/h • IV • continuous × 3–5 d
    trigger: Suspected variceal bleed
    Splanchnic vasoconstriction (Baveno VII 2022; AASLD 2023)
  3. 3. ceftriaxone
    1 g IV • IV • daily × 5–7 d
    trigger: Cirrhosis with GI bleed
    Cochrane reduces mortality + SBP (Baveno VII 2022; AASLD 2023; EASL 2018)
  4. 4. pantoprazole bolus + infusion
    80 mg IV → 8 mg/h × 72 h • IV • continuous × 72 h
    trigger: Mixed source possibility
    PUD coverage (ACG 2021 UGIB)
  5. 5. lactulose
    30–45 mL • PO/PR • q6h
    trigger: HE risk after blood meal
    Prevent HE (AASLD 2023 HE; EASL 2018)

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Hematemesis (red or coffee-ground) (Baveno VII de Franchis 2022); Melena or hematochezia in cirrhotic patient (Baveno VII 2022; AASLD 2023); Syncope or hypotension in cirrhotic patient (Baveno VII 2022 acute bleed criteria).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute variceal hemorrhage (esophageal / gastric / ectopic)** (gi.variceal_bleed.v1).
Phenotype framing: Esophageal vs gastric vs ectopic varices vs PHT gastropathy vs non-variceal — PUD, Mallory-Weiss, malignancy (Baveno VII 2022; ACG 2021)
Scope: Confirm variceal source via EGD; differentiate from non-variceal UGIB; identify high-risk features (Baveno VII 2022 de Franchis; AASLD 2023)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acute variceal hemorrhage bundle**.
1. octreotide 50 mcg IV bolus then 50 mcg/h infusion IV continuous × 3–5 d (somatostatin_analog, first line) — Reduces splanchnic flow; bridge to EGD (Baveno VII 2022 de Franchis PMID 35120736; AASLD 2023)
2. ceftriaxone 1 g IV IV daily × 5–7 d (cephalosporin_3rd_gen, first line) — Reduces SBP and infection mortality (Cochrane; Baveno VII 2022; AASLD 2023; EASL 2018)
3. terlipressin 2 mg IV q4h × 24 h then 1 mg IV q4h IV q4h (vasopressin_analog, second line) — Where available; CONFIRM trial benefit in HRS-AKI; ischemic risk (Baveno VII 2022; EASL 2018)
4. pantoprazole 80 mg IV bolus then 8 mg/h IV continuous × 72 h then PO (PPI, add on) — Acid suppression for PUD if mixed source (ACG 2021 UGIB)
5. lactulose 30–45 mL PO/PR q6h titrate (osmotic_laxative, add on) — HE risk after blood meal (AASLD 2023 HE guideline; EASL 2018)
6. rifaximin 550 mg PO BID (non_absorbable_antibiotic, add on) — Adjunct to lactulose for HE prevention (Bass NEJM 2010; AASLD 2023)

Setting playbook (ed) — Resuscitate, bundle therapy, EGD ≤12 h, decide TIPS vs ward
7. IV fluid + restrictive transfusion crystalloid bolus, PRBC to Hgb 7–8 IV titrated — Hgb <7 or hemodynamic instability (Villanueva NEJM 2013 PMID 23281973; Baveno VII 2022)
8. octreotide 50 mcg IV bolus + 50 mcg/h IV continuous × 3–5 d — Suspected variceal bleed (Splanchnic vasoconstriction (Baveno VII 2022; AASLD 2023))
9. ceftriaxone 1 g IV IV daily × 5–7 d — Cirrhosis with GI bleed (Cochrane reduces mortality + SBP (Baveno VII 2022; AASLD 2023; EASL 2018))
10. pantoprazole bolus + infusion 80 mg IV → 8 mg/h × 72 h IV continuous × 72 h — Mixed source possibility (PUD coverage (ACG 2021 UGIB))
11. lactulose 30–45 mL PO/PR q6h — HE risk after blood meal (Prevent HE (AASLD 2023 HE; EASL 2018))

Non-pharmacologic actions:
- EGD within 12 h of presentation, preferably 6-12 h (Baveno VII 2022; AASLD 2023)
- Band ligation for esophageal varices (Baveno VII 2022 de Franchis)
- Cyanoacrylate / glue for gastric varices (Baveno VII 2022; AASLD 2023)
- Balloon tamponade (Sengstaken-Blakemore / Minnesota) as bridge <=24 h, secured airway (Baveno VII 2022; EASL 2018)
- Early TIPS within 72 h for Child-Pugh B with active bleed at EGD or Child-Pugh C <=14 (Garcia-Pagan NEJM 2010 PMID 20573925; Baveno VII 2022)
- Intubation if active hematemesis with airway concern (Baveno VII 2022)

AVOID / contraindication checks:
- Terlipressin ischemic monitor cardiac
- Transfusion restrictive 7 target
- DOAC reversal targeted not routine
- Platelet transfusion only if active bleed and plt 50

Monitoring

Regimen monitoring:
- Hgb q6h first 24h then q12h — Baveno VII 2022; Villanueva NEJM 2013
- lactate q6h until resolved — Baveno VII 2022
- BMP q12h — Baveno VII 2022; AASLD 2023
- AC reversal PT INR post — Baveno VII 2022; EASL 2018
- symptoms of HE q4h — AASLD 2023 HE

Setting (ed) monitoring:
- Hgb q6h x 24 h (Baveno VII 2022; Villanueva NEJM 2013)
- Continuous SpO2 + ECG (Baveno VII 2022)
- Urine output (Baveno VII 2022 resuscitation)

Follow-up plan: Hepatology q1-3 mo; serial EVL until obliteration; transplant evaluation; HE management (Baveno VII 2022 secondary prophylaxis; AASLD 2023)
- Close-out criterion: Follow-up booked

Monitoring phase: Hgb q6h initially, vitals q1h, ammonia, encephalopathy, infection signs, AC plan (Baveno VII 2022; AASLD 2023)

Disposition

Current setting: ed — Resuscitate, bundle therapy, EGD ≤12 h, decide TIPS vs ward

Disposition criteria:
- ICU if active bleed / hemodynamic instability / encephalopathy / intubated (Baveno VII 2022; AASLD 2023)
- Step-down to ward when stable post-EGD (Baveno VII 2022)

Escalation triggers (move to higher acuity):
- Refractory bleeding → balloon tamponade → TIPS (Baveno VII 2022; Garcia-Pagan NEJM 2010)
- TIPS contraindication → surgical shunt or transplant evaluation (Baveno VII 2022; AASLD 2023)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Hematemesis with hypotension or hemoglobin drop ≥2 g/dL
- [LIFE_THREATENING] Continued bleeding despite band ligation / glue
- [SEVERE] Child-Pugh B with active bleed at EGD or Child-Pugh C ≤14 within 72 h of EGD

Citations

- Baveno VII consensus (J Hepatol 2022); AASLD 2017 portal HTN; Garcia-Pagan NEJM 2010 (early TIPS); Villanueva NEJM 2013 (restrictive transfusion) [PMID:35120736](https://pubmed.ncbi.nlm.nih.gov/35120736/)
- Cited evidence (PMID 20573925) [PMID:20573925](https://pubmed.ncbi.nlm.nih.gov/20573925/)
- Cited evidence (PMID 23281973) [PMID:23281973](https://pubmed.ncbi.nlm.nih.gov/23281973/)
- Cited evidence (PMID 27786365) [PMID:27786365](https://pubmed.ncbi.nlm.nih.gov/27786365/)

Last reconciled with current guidelines: 2026-05-22.
References
  • Baveno VII consensus (J Hepatol 2022); AASLD 2017 portal HTN; Garcia-Pagan NEJM 2010 (early TIPS); Villanueva NEJM 2013 (restrictive transfusion) — PMID:35120736
  • Cited evidence (PMID 20573925) — PMID:20573925
  • Cited evidence (PMID 23281973) — PMID:23281973
  • Cited evidence (PMID 27786365) — PMID:27786365