A 48-year-old with known alcohol-related cirrhosis re-bleeds 6 hours after band ligation. BP 80/50, Hb dropped from 78 to 62. What now?

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Accepted Answer

This is a **failed endoscopic haemostasis** in a decompensated cirrhotic — high mortality. I would run **ABCDE** and the **BSG/Baveno VII rescue cascade**.

**Resuscitate.** Activate the **major haemorrhage protocol**. Two large-bore IV, arterial line, urinary catheter. **Restrictive transfusion** strategy — Hb target 70–80 g/L (Villanueva NEJM 2013, endorsed by Baveno VII; over-transfusion raises portal pressure and re-bleeding). Correct coagulopathy pragmatically — **platelets >50, fibrinogen >1.5** with cryoprecipitate or fibrinogen concentrate; routine FFP is not recommended.

**Pharmacology.** Continue **terlipressin 2 mg IV 4-hourly** (caution in IHD/PVD) and **IV ceftriaxone 1 g daily** — antibiotics reduce mortality and re-bleeding in cirrhotic GI bleeds (BSG 2015 / EASL 2018).

**Airway.** This patient has dropped his BP and may have encephalopathy — **early elective intubation** before repeat endoscopy is safer than aspiration during a crash induction.

**Bridge with balloon tamponade.** Insert a **Sengstaken-Blakemore (oesophageal varices) or Linton (gastric varices)** tube as a temporising measure — only after airway is secured, only by trained staff, gastric balloon first, maximum 24 hours.

**Definitive haemostasis.**
- Call the **on-call endoscopist and tertiary hepatology now**. Repeat OGD with re-banding or cyanoacrylate glue for gastric varices.
- **Salvage TIPSS within 72 hours** is indicated for failure of endoscopic therapy (BSG/Baveno VII). Early pre-emptive TIPSS (within 72 h of presentation) reduces mortality in high-risk patients (Child-Pugh C 10–13 or B with active bleed).

**Holistic.** Liaise with **hepatology / transplant centre** about UKELD, consider alcohol-care team input, and have an honest conversation with the family about prognosis and ceiling of care including ITU candidacy.

I would document carefully, debrief the team, and Datix if there were avoidable delays in any step.

Refractory variceal haemorrhage after first endoscopy

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