In this episode of Hospital Medicine Unplugged, we dive into acute variceal bleeding—a high-stakes emergency in cirrhotic patients where seconds count and outcomes hinge on rapid, coordinated care.

We start with the crash course in recognition and stabilization: ICU-level monitoring, two large-bore IVs, and cautious transfusion—targeting a hemoglobin around 7 g/dL to avoid portal pressure spikes and rebleeding. Protect the airway early; intubate if hematemesis or encephalopathy loom.

Pharmacologic therapy doesn’t wait for endoscopy. Hit fast with octreotide (50 μg bolus → 50 μg/h infusion) or terlipressin/somatostatin if available, and start ceftriaxone 1 g IV daily to cover against bacterial translocation and sepsis. These moves—simple but evidence-based—slash early mortality and infection risk.

Then comes the endoscopic moment: perform urgent EGD within 12 hours. Band the culprit—endoscopic variceal ligation (EVL) is first-line for esophageal varices, while cyanoacrylate injection (± coils) dominates for gastric or ectopic sites. Visualization gets a boost from IV erythromycin pre-procedure. If bleeding laughs in your face—bridge with balloon tamponade or self-expanding stent while prepping for TIPS.

TIPS saves lives when all else fails or when the odds are stacked: Child-Pugh C (10–13) or B >7 with active bleeding—go early (within 24–72 hours). It decompresses the portal system, quells refractory bleeding, and buys survival time.

Once the storm calms, secondary prophylaxis takes over. Combine nonselective beta-blockers (carvedilol preferred at 12.5 mg daily) with repeat EVL every 2–4 weeks until varices vanish. No monotherapy—combo therapy halves rebleeding and boosts survival. For gastric or ectopic varices, keep repeating glue injection or move to BRTO or TIPS if anatomy and expertise allow.

Avoid the traps:
• Overtransfusion—raises portal pressure.
• Routine plasma/platelet correction—no proven benefit.
• Early steroid use or unguarded sedation—risk spirals fast.

Complications hit early and hard—shock, infection, encephalopathy, AKI, and early rebleeding top the list. Six-week mortality can reach 40% in advanced cirrhotics, but drops sharply with prompt vasoactive therapy, antibiotics, and endoscopic control.

Predict death early: Child-Pugh C, MELD ≥19, active bleeding at endoscopy, transfusion >4 units, or renal/hepatic failure—each turns the curve downward. These patients may benefit from pre-emptive TIPS and aggressive ICU support.

Special plays:
• GOV1 (lesser curvature) → treat like esophageal varices (EVL).
• GOV2/IGV1 (fundal) → cyanoacrylate injection ± coil; consider BRTO if available.
• Ectopic varices → tailored endoscopic or radiologic therapy.
• Non-cirrhotic portal hypertension (e.g., splenic vein thrombosis) → definitive fix may be splenectomy or stenting.

We close with the system bundle that keeps patients alive:
(1) Early airway + restrictive transfusion;
(2) Immediate vasoactive + antibiotic therapy;
(3) Urgent endoscopy (<12 h);
(4) TIPS within 72 h for high-risk;
(5) NSBB + EVL combo for secondary prevention;
(6) Multidisciplinary follow-up with hepatology, radiology, and ICU care.

Rapid, protocolized, and team-driven—control the bleed, decompress the pressure, and protect the liver. This is how you turn variceal crisis into survival.