1. If airway and/or breathing are compromised, perform endotracheal intubation and institute mechanical ventilation. This facilitates Sengstaken-type tube placement and endoscopy but may be associated with severe hypotension secondary to covert hypovolaemia. If possible, ensure adequate intravascular filling before intubation.

2. Fluid resuscitation with colloid and blood with blood products as appropriate to correct any coagulopathy. Ensure good venous access (at least two 14G cannulae). Group-specific or O-negative blood may be needed for emergency use. Maintain haemoglobin >10g/dl and have at least 4 units of cross-matched blood available for urgent transfusion. There is a theoretical risk that over-transfusion may precipitate further bleeding by raising portal venous pressure. Cardiac output monitoring should be considered if the patient remains haemodynamically unstable or there is a history of heart disease.

3. If bleeding is torrential, insert a Sengstaken-type tube and commence administration of IV vasopressin/terlipressin (q.v.).

4. Gentle placement of a large-bore nasogastric tube is a reasonably safe procedure that facilitates drainage of blood, lessens the risk of aspiration and can be used to assess continuing blood loss.

5. Perform urgent fibreoptic endoscopy to exclude other sources of bleeding. This also permits variceal banding or local injection of a sclerosing agent. Bleeding is arrested in up to 90% of cases. Endoscopy may be impossible in the short term if bleeding is too severe. It may have to be delayed for 6-24h until a period of tamponade by the Sengstaken-type tube ± vasopressin has enabled some control of the bleeding.

6. Either octreotide, vasopressin or terlipressin can be administered for severe bleeding, or prophylaxis against fresh bleeding. Vasopressin controls bleeding in approximately 60% of cases and its efficacy and safety appears to be enhanced by concurrent GTN. The side-effect profile of terlipressin is lower as it does not appear to precipitate as much mesenteric, cardiac or digital ischaemia, Octreotide is a somatostatin analogue but longer-acting than its parent compound; like somatostatin, it is probably as effective as vasopressin but without the side-effects.

7. If bleeding continues after prolonged balloon tamponade (2-3 days) and repeated endoscopy, consider transjugular intrahepatic portosystemic stented shunt (TIPSS). This can be performed quickly and carries a relatively low mortality compared to surgery although the risk of encephalopathy is increased.

8. The traditional alternative to TIPSS is oesophageal transection (now performed with a staple gun) with or without devascularisation. Mortality in the acute situation is of the order of 30%.


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