Variceal bleeding
Call 999 or go to A&E if
- Call 999 or go to A&E if you are vomiting blood, your poo is very dark or black, you have difficulty breathing or shortness of breath, you feel suddenly confused, feel dizzy or have difficulty staying awake.
Do not drive to A&E. Ask someone to drive you or call 999 and ask for an ambulance. Bring any medicines you take with you.
Prophylactic antibiotic therapy is offered at presentation to patients with suspected or confirmed variceal bleeding.
The reason antibiotics come first is not the bleeding. Patients with variceal upper gastrointestinal bleeding are prone to infection; infection adversely affects renal function and commonly precipitates hepatorenal failure, and early antibiotic therapy reduces these risks.
NICE — Quality statement 6, Rationale
The exact wording of the source
Quality statement 6, Rationale · status: current, verified 2026-09-01
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People with variceal acute upper gastrointestinal bleeding are prone to infection. Infection has adverse effects on renal function and commonly precipitates hepatorenal failure, characterised by oliguria, sodium and fluid retention and death. Early antibiotic therapy reduces these risks.
Band ligation is used for upper gastrointestinal bleeding from oesophageal varices.
NICE — Recommendation 1.5.3, subheading Oesophageal varices
The exact wording of the source
Recommendation 1.5.3, subheading Oesophageal varices · status: current, verified 2026-09-01
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Use band ligation in patients with upper gastrointestinal bleeding from oesophageal varices.
Transjugular intrahepatic portosystemic shunts are considered if bleeding from oesophageal varices is not controlled by band ligation. NICE's verb here is consider, not offer.
NICE — Recommendation 1.5.4, subheading Oesophageal varices
The exact wording of the source
Recommendation 1.5.4, subheading Oesophageal varices · status: current, verified 2026-09-01
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Consider transjugular intrahepatic portosystemic shunts (TIPS) if bleeding from oesophageal varices is not controlled by band ligation.
For bleeding from gastric varices, endoscopic injection of N-butyl-2-cyanoacrylate is offered.
NICE — Recommendation 1.5.5, subheading Gastric varices
The exact wording of the source
Recommendation 1.5.5, subheading Gastric varices · status: current, verified 2026-09-01
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Offer endoscopic injection of N-butyl-2-cyanoacrylate to patients with upper gastrointestinal bleeding from gastric varices.
The BSG and BASL admission care bundle recommends a restrictive red cell transfusion target of 70-80 g/L in haemodynamically stable patients with upper gastrointestinal bleeding. In haemodynamic instability the transfusion strategy depends on the clinical scenario.
British Society of Gastroenterology, British Association for the Study of the Liver and Society for Acute Medicine — Table 1, red cell transfusion row, quality of evidence 'High', audit standard 90% · British Society of Gastroenterology, British Association for the Study of the Liver and Society for Acute Medicine — Body, section 'Transfusion: red blood cells', sentence following the recommendation
The exact wording of the source
Table 1, red cell transfusion row, quality of evidence 'High', audit standard 90% · status: current, verified 2026-09-01
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We recommend a restrictive transfusion target of 70–80 g/L in haemodynamically stable patients with upper GI bleeding.
Body, section 'Transfusion: red blood cells', sentence following the recommendation · status: current, verified 2026-09-01
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However, in the case of haemodynamic instability, the transfusion strategy will depend on the clinical scenario.
Terlipressin is offered at presentation in suspected variceal bleeding, and stopped after definitive haemostasis or after 5 days. NICE records that at the time of publication terlipressin was licensed for a maximum of 72 hours, so this duration is an off-label use.
NICE — Recommendation 1.5.1, section 1.5 Management of variceal bleeding · NICE — Footnote to recommendation 1.5.1
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Recommendation 1.5.1, section 1.5 Management of variceal bleeding · status: current, verified 2026-09-01
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Offer terlipressin to patients with suspected variceal bleeding at presentation. Stop treatment after definitive haemostasis has been achieved, or after 5 days, unless there is another indication for its use.
Footnote to recommendation 1.5.1 · status: current, verified 2026-09-01
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At the time of publication (June 2012), terlipressin was indicated for the treatment of bleeding from oesophageal varices, with a maximum duration of treatment of 72 hours (3 days). Prescribers should consult the relevant summary of product characteristics.
MHRA advises avoiding terlipressin in patients with advanced renal dysfunction, defined as a baseline serum creatinine at or above 442 micromol/L, unless the benefit is judged to outweigh the risks.
Medicines and Healthcare products Regulatory Agency — Advice for healthcare professionals, third bullet, first nested sub-bullet · Medicines and Healthcare products Regulatory Agency — Advice for healthcare professionals, third bullet, parent clause
The exact wording of the source
Advice for healthcare professionals, third bullet, first nested sub-bullet · status: current, verified 2026-09-01
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avoid terlipressin in those with advanced renal dysfunction (baseline serum creatinine at or above 442 µmol/L (5.0 mg/dL)), unless the benefit is judged to outweigh the risks
Advice for healthcare professionals, third bullet, parent clause · status: current, verified 2026-09-01
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since both advanced renal impairment and advanced liver impairment were risk factors for poorer outcomes in patients with type 1 hepatorenal syndrome:
MHRA advises avoiding terlipressin in patients with severe liver disease, which it defines as acute-on-chronic liver failure grade 3, a MELD score of 39 or more, or both, unless the benefit is judged to outweigh the risks.
Medicines and Healthcare products Regulatory Agency — Advice for healthcare professionals, third bullet, second nested sub-bullet
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Advice for healthcare professionals, third bullet, second nested sub-bullet · status: current, verified 2026-09-01
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avoid terlipressin in those with severe liver disease (defined as Acute-on-Chronic Liver Failure (ACLF) grade 3, a Model for End-stage Liver Disease (MELD) score ≥ 39, or both), unless the benefit is judged to outweigh the risks
Patients with new-onset breathing difficulties, or worsening of existing respiratory disease, are stabilised before terlipressin is given, and monitored closely during treatment.
Medicines and Healthcare products Regulatory Agency — Advice for healthcare professionals, fourth bullet
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Advice for healthcare professionals, fourth bullet · status: current, verified 2026-09-01
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stabilise patients with new-onset breathing difficulties or worsening of existing respiratory disease before administering terlipressin and monitor closely during treatment
In signs or symptoms of respiratory failure or fluid overload, a reduction in albumin dose is considered, and terlipressin is discontinued if symptoms are severe or do not resolve.
Medicines and Healthcare products Regulatory Agency — Advice for healthcare professionals, fifth bullet
The exact wording of the source
Advice for healthcare professionals, fifth bullet · status: current, verified 2026-09-01
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consider a reduction in albumin dose in patients with signs or symptoms of respiratory failure or fluid overload; discontinue terlipressin if symptoms are severe or do not resolve
Patients receiving terlipressin are monitored daily for signs and symptoms of infection.
Medicines and Healthcare products Regulatory Agency — Advice for healthcare professionals, sixth bullet
The exact wording of the source
Advice for healthcare professionals, sixth bullet · status: current, verified 2026-09-01
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monitor patients daily for signs and symptoms of infection
Blood pressure, heart rate, oxygen saturation, serum sodium and potassium, and fluid balance are monitored during terlipressin treatment. Terlipressin may induce myocardial ischaemia and pulmonary vascular congestion, especially in those with pre-existing cardiopulmonary disease.
Medicines and Healthcare products Regulatory Agency — Advice for healthcare professionals, seventh bullet
The exact wording of the source
Advice for healthcare professionals, seventh bullet · status: current, verified 2026-09-01
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monitor blood pressure, heart rate, oxygen saturation, serum sodium and potassium levels, and fluid balance; terlipressin may induce myocardial ischaemia and pulmonary vascular congestion, especially in those with pre-existing cardiopulmonary disease
Related
- Acute decompensation — can be a presentation of
- Octreotide — is treated with
- Antimicrobial therapy in liver disease — can be prevented with
- Terlipressin — is treated with
- Hepatic encephalopathy — related through acute decompensation
- Ascites — related through acute decompensation
What we have not established
Relationships involving Variceal bleeding that we have not evidenced are listed, never drawn — a line would read as a weak relationship, which is a different and false claim.
- Varices → Variceal bleeding — not established
- Variceal bleeding → Hepatic encephalopathy — not established
- Variceal bleeding → Variceal band ligation — not established
Evidence search date: 2026-09-01
Content reviewed and approved
What we have not established here
Known gaps on this concept:
NO PLAIN-LANGUAGE LAYER. Nothing in the ledger explains what a varix is to a patient. The BSG 2015 variceal haemorrhage guideline is openly accessible at PMC4680175 and has not been extracted; under ADR-0024 this is backlog, not a blocker.
The escalation step for gastric varices - CG141 1.5.6, TIPS if cyanoacrylate injection does not control the bleeding - has not been read verbatim and is not claimed. This page therefore stops the gastric pathway before its escalation step, and says so here rather than implying the pathway is complete.
No terlipressin dose. The MHRA Drug Safety Update contains no dose, no infusion rate and no maximum duration - the verifying agent searched the whole document to confirm that. The care bundle gives a variceal dose and a different hepatorenal dose; neither is rendered here, because rendering two unreconciled dosing schemes on one page is worse than rendering none.
No content on secondary prophylaxis after a bleed, on primary prophylaxis, or on the timing of endoscopy.
No specialist or research resolution.
What has changed here
2026-09-01 — Concept created at clinical resolution only, as the first page written under ADR-0025.
Phase 14 declared that its clinical claims were rendered nowhere. This closes that for variceal bleeding and tests whether the safety-dependency machinery actually binds at render time.