Guideline sources The following summarized guidelines for the evaluation and management of variceal hemorrhage are prepared by our editorial team based on guidelines from the European Society of Gastrointestinal Endoscopy (ESGE 2022), the British Society for Haematology (BSH 2022), the American Gastroenterological Association (AGA 2021), the Advancing Liver Therapeutic Approaches Consortium (ALTA 2021), the European Association for the Study of the Liver (EASL 2018), the American Association for the Study of Liver Diseases (AASLD 2017), the British Society of Gastroenterology (BSG 2015), and the American Society for Gastrointestinal Endoscopy (ASGE 2014). 1 2 3 4 5 6 7 8 Calculator Calculator Calculat Child-Pugh score for mortality in Complete Rockall score for predi Initial R https://web.pathway.md/diseases/recplXN8m9B80jYmF 1/12 6/29/23, 3:23 AM Variceal hemorrhage Pathway Guidelines 1. Screening and diagnosis Screening for varices: As per EASL 2018 guidelines: Perform upper gastrointestinal endoscopy to screen for gastroesophageal varices in patients with decompensated liver cirrhosis, unless previously diagnosed and treated. Report the presence, size and presence of red wale marks. B Perform repeated upper gastrointestinal endoscopy every year in patients with liver cirrhosis without varices on screening upper gastrointestinal endoscopy if the etiological factor persists and/or the state of liver decompensation continues. Consider prolonging the screening interval in the remaining patients. B As per AASLD 2017 guidelines, perform screening endoscopy for the diagnosis of gastroesophageal varices when the diagnosis of cirrhosis is made. E Show 4 more As per BSG 2015 guidelines: Perform screening endoscopy in all patients with cirrhosis at the time of diagnosis. A Consider repeating endoscopy at 2-3-year intervals if no varices are found at the time of first endoscopy. C 2. Classification and risk stratification Risk stratification: obtain risk stratification in patients with advanced chronic liver disease presenting with suspected acute variceal bleeding according to the Child-Pugh score and Model for End-stage Liver Disease score, and by documentation of active/inactive bleeding at the time of upper gastrointestinal endoscopy. A 3. Diagnostic investigations Upper gastrointestinal endoscopy: As per ESGE 2022 guidelines: Obtain endoscopic evaluation within 12 hours from the time of presentation in patients with suspected variceal hemorrhage, provided the patient has been hemodynamically resuscitated. B Administer IV erythromycin 250 mg, if not contraindicated, 30-120 minutes before gastrointestinal endoscopy in patients with suspected acute variceal hemorrhage. A As per AGA 2021 guidelines: Obtain initial endoscopic evaluation to identify the bleeding source and classify the variceal bleeding site. Offer initial therapy for bleeding gastric varices focusing on acute hemostasis for hemodynamic stabilization and plan for further diagnostic evaluation and/or transfer to a tertiary care center with expertise in gastric varices management. B https://web.pathway.md/diseases/recplXN8m9B80jYmF 2/12 6/29/23, 3:23 AM Variceal hemorrhage Pathway Determine definitive therapy for gastric variceal hemorrhage based on the endoscopic appearance of gastric varix, the underlying vascular anatomy, the presence of comorbid portal hypertensive complications, and available local resources, ideally via a multidisciplinary discussion between the gastroenterologist or hepatologist and the interventional radiologist. B As per EASL 2018 guidelines: Perform upper gastrointestinal endoscopy within the first 12 hours after admission once hemodynamic stability has been achieved, to ascertain the cause of hemorrhage and to provide endoscopic therapy. B Consider administering pre-endoscopy erythromycin (250 mg IV 30-120 minutes before), in the absence of contraindications (QT prolongation), to facilitate the procedure. B As per AASLD 2017 guidelines, perform upper gastrointestinal endoscopy within 12 hours of admission, and once the patient is hemodynamically stable, in patients presenting with acute esophageal variceal bleeding. E As per BSG 2015 guidelines, obtain endoscopy in unstable patients with severe acute upper gastrointestinal bleeding immediately after resuscitation. B Obtain endoscopy within 24 hours of admission in all other patients with upper gastrointestinal bleeding. B As per ASGE 2014 guidelines: Perform urgent endoscopy within 12 hours of admission in patients with suspected acute variceal hemorrhage. B Consider intubating patients before endoscopy to prevent aspiration during the procedure, especially in patients with encephalopathy. C Evaluation for portal hypertension: diagnose clinically significant portal hypertension based on the presence of gastroesophageal varices on endoscopy. E Show 2 more 4. Medical management Intravenous fluids: initiate prompt volume replacement with colloids and/or crystalloids to restore and maintain hemodynamic stability. B Do not use starch for volume replacement. A Vasoactive agents: As per ESGE 2022 guidelines, administer vasoactive agents (terlipressin, octreotide, or somatostatin) initiated at the time of presentation in patients with suspected acute variceal bleeding and continue for a duration of up to 5 days. A As per EASL 2018 guidelines, administer vasoactive drugs as soon as acute variceal bleeding is suspected and before endoscopy. Administer terlipressin, somatostatin, or octreotide as accepted options. Administer therapy for 3-5 days in patients with acute variceal bleeding. A As per AASLD 2017 guidelines: Administer vasoactive drugs (somatostatin, octreotide, vasopressin, or terlipressin) as soon as variceal hemorrhage is suspected. E https://web.pathway.md/diseases/recplXN8m9B80jYmF 3/12 6/29/23, 3:23 AM Variceal hemorrhage Pathway Continue IV vasoactive drugs for 2-5 days and initiate nonselective -blockers once vasoactive drugs are discontinued in patients not undergoing early TIPS insertion. E As per BSG 2015 guidelines, administer vasoconstrictors, such as terlipressin or somatostatin, in all patients with variceal hemorrhage, starting as soon as variceal bleeding is suspected and continuing until hemostasis is achieved or for up to 5 days. Consider administering octreotide if terlipressin or somatostatin is unavailable. A As per ASGE 2014 guidelines, administer octreotide in patients with suspected variceal hemorrhage and continue for 3-5 days after endoscopy if variceal hemorrhage is confirmed. B Tranexamic acid: do not use tranexamic acid in patients with acute gastrointestinal bleeding. D Antibiotic prophylaxis: As per ESGE 2022 guidelines, administer antibiotic prophylaxis with ceftriaxone 1 g/day for up to 7 days, or in accordance with local antibiotic resistance and patient allergies, in all patients with advanced chronic liver disease presenting with acute variceal hemorrhage. A As per EASL 2018 guidelines, administer antibiotic prophylaxis in patients with cirrhosis with acute gastrointestinal bleeding to reduce the incidence of infections and improve control of bleeding and survival. Initiate treatment on the presentation of bleeding and continue for up to 7 days. A Administer ceftriaxone 1 g/24 hours as the first choice in patients with decompensated cirrhosis, already on quinolone prophylaxis, and in hospital settings with a high prevalence of quinolone-resistant bacterial infections. Administer oral quinolones, such as norfloxacin 400 mg BID, in the remaining patients. A As per AASLD 2017 guidelines, administer short-term antibiotic prophylaxis in patients with cirrhosis and gastrointestinal bleeding. Administer ceftriaxone (1 g IV once daily) as the antibiotic of choice for prophylaxis, and complete a maximum of 7 days of treatment. Consider discontinuing antibiotics when hemorrhage has resolved and vasoactive drugs are discontinued. E Landmark trials: Ceftriaxone prophylaxis in cirrhosis with GI bleeding In patients with advanced cirrhosis (at least 2 of the following: ascites, severe malnutrition, encephalopathy, or bilirubin > 3 mg/dL) and gastrointestinal hemorrhage, ceftriaxone was superior to norfloxacin with respect to proved or possible infections at 10 days. Fernandez J et al. Gastroenterology. 2006 Oct. As per BSG 2015 guidelines, administer antibiotics in all patients with suspected or confirmed variceal bleeding. A As per ASGE 2014 guidelines, administer prophylactic antibiotics for 7 days in patients with cirrhosis presenting with variceal hemorrhage. A Lactulose: consider administering prophylactic lactulose to prevent encephalopathy in patients with bleeding. B https://web.pathway.md/diseases/recplXN8m9B80jYmF 4/12 6/29/23, 3:23 AM Variceal hemorrhage Pathway Proton pump inhibitors: do not use PPIs for the management of patients with variceal hemorrhage unless otherwise required for peptic ulcer disease. D Medications to avoid: avoid using -blockers and vasodilators during the acute bleeding episode. D 5. Inpatient care Inpatient monitoring: As per BSH 2022 guidelines, pay special attention to heightened risks of raising vascular pressures with excessive plasma transfusions and the limitations of standard coagulation tests to monitor coagulation status in patients with liver disease. B As per EASL 2018 guidelines, obtain close monitoring in patients with acute gastrointestinal bleeding both due to gastroesophageal varices or non-variceal lesions as it carries a high incidence of complications and mortality in decompensated cirrhosis. B 6. Therapeutic procedures Blood product transfusion: As per ESGE 2022 guidelines, use a restrictive RBC transfusion strategy, with a Hgb threshold of 70 g/L prompting RBC transfusion in hemodynamically stable patients with acute upper gastrointestinal hemorrhage and no history of CVD. Set a post-transfusion target Hgb of 70-90 g/L. B As per EASL 2018 guidelines, use a restrictive transfusion strategy in most patients with a Hgb threshold for transfusion of 7 g/dL and a target range of 7-9 g/dL. A As per AASLD 2017 guidelines, administer packed RBC transfusion when the Hgb level reaches a threshold of around 7 g/dL, with the goal of maintaining Hgb 7-9 g/dL. E Landmark trials: Transfusion strategies for acute upper GI bleeding In patients with severe acute upper gastrointestinal bleeding, restrictive blood transfusion therapy was superior to liberal blood transfusion therapy with respect to death at 45 days. Villanueva C et al. N Engl J Med. 2013 Jan 3. As per BSG 2015 guidelines, administer blood, platelets, and clotting factors in patients with massive bleeding in line with local protocols. B Show 7 more Endoscopic variceal ligation: As per ESGE 2022 guidelines, perform endoscopic band ligation for the treatment of acute esophageal variceal hemorrhage. A As per EASL 2018 guidelines: https://web.pathway.md/diseases/recplXN8m9B80jYmF 5/12 6/29/23, 3:23 AM Variceal hemorrhage Pathway Perform variceal ligation within the same procedure when acute variceal bleeding is confirmed by endoscopy. A Combine vasoactive drugs and endoscopic ligation as the first therapeutic option in acute variceal bleeding. A As per AASLD 2017 guidelines: Perform endoscopic variceal ligation if a variceal source for gastrointestinal bleeding is confirmed/suspected. E Perform either endoscopic variceal ligation (if technically feasible) or cyanoacrylate glue injection, if available, in patients with type 1 gastroesophageal varices. E As per BSG 2015 guidelines, perform variceal band ligation as the preferred method for endoscopic treatment. A As per ASGE 2014 guidelines, perform endoscopic variceal ligation in patients with acute variceal hemorrhage or in patients with varices and stigmata of recent hemorrhage. B Endoscopic sclerotherapy: As per AGA 2021 guidelines, administer cyanoacrylate injection to bleeding gastric varices as the treatment of choice for definitive endoscopic therapy. Do not add plant-based oils, such as lipiodol, to cyanoacrylate injections. B As per AASLD 2017 guidelines, consider administering cyanoacrylate glue injection as an option if TIPS or balloon-occluded retrograde transvenous obliteration is not technically feasible. E As per ASGE 2014 guidelines, consider performing endoscopic sclerotherapy if endoscopic variceal ligation is technically difficult to perform. C Transjugular intrahepatic portosystemic shunt: As per ESGE 2022 guidelines: Consider performing preemptive TIPS placement within 72 hours (preferably within 24 hours) in patients at high risk for recurrent esophageal variceal bleeding following successful endoscopic hemostasis (Child-Pugh C 13 or Child-Pugh B > 7 with active esophageal variceal hemorrhage at the time of endoscopy despite vasoactive agents, or hepatic venous pressure gradient > 20 mmHg). B Consider performing urgent rescue TIPS placement (where available) in patients with persistent esophageal variceal bleeding despite vasoactive pharmacological and endoscopic hemostasis therapy. B As per AGA 2021 guidelines: Consider performing TIPS placement for the management of gastric vatical hemorrhage when there is significant inflow to the gastric varices from the coronary vein and/or significant comorbid complications from portal hypertension. C Perform endovascular sclerosis and/or direct embolization of gastric varices when feasible if TIPS placement is performed for the management of gastric variceal hemorrhage. B As per ALTA 2021 guidelines, perform preemptive TIPS creation in patients with acute variceal hemorrhage successfully banded but meeting high-risk criteria for rebleeding (Child- Turcotte-Pugh class C with 10-13 points or Child-Turcotte-Pugh class B > 7 points with active https://web.pathway.md/diseases/recplXN8m9B80jYmF 6/12 6/29/23, 3:23 AM Variceal hemorrhage Pathway bleeding at endoscopy). Perform TIPS within 72 hours of admission in patients without contraindications to TIPS. B Show 4 more As per EASL 2018 guidelines: Consider performing early preemptive covered TIPS placement within 24-72 hours in selected high-risk patients, such as with Child class C with a score < 14. B Perform TIPS placement as the rescue therapy of choice in patients with persistent bleeding or early rebleeding despite treatment with vasoactive drugs plus variceal ligation, and prophylactic antibiotics. A As per AASLD 2017 guidelines, perform an early preemptive TIPS placement within 72 hours of endoscopy/endoscopic variceal ligation in patients at high risk of treatment failure or rebleeding, in the absence of contraindications for TIPS. E Show 4 more Landmark trials: Early TIPS for variceal hemorrhage In patients with cirrhosis and acute variceal bleeding who had been treated with vasoactive drugs plus endoscopic therapy, early TIPS implantation was superior to vasoactive drugs and endoscopic band ligation with respect to freedom from rebleeding or failure to control bleeding. Garcia-Pagan JC et al. N Engl J Med. 2010 Jun 24. As per BSG 2015 guidelines, consider performing early covered TIPS (< 72 hours after index variceal bleed), after satisfactory hemostasis and depending on local resources, in selected patients with Child's B cirrhosis and active bleeding or Child's C cirrhosis with Child's score < 14. C As per ASGE 2014 guidelines, perform TIPS creation in patients failed combined endoscopic and pharmacological therapies. B Balloon-occluded retrograde transvenous obliteration: Consider performing balloon-occluded retrograde transvenous obliteration as the optimal endovascular therapy for gastric variceal hemorrhage when a gastrorenal shunt is present, local expertise is available, and when severe comorbid complications of portal hypertension are absent. C As per AASLD 2017 guidelines, perform TIPS placement or balloon-occluded retrograde transvenous obliteration as first-line treatments in the prevention of rebleeding in patients recovered from type 2 gastroesophageal or type 1 isolated gastric variceal hemorrhage. E Balloon tamponade: As per EASL 2018 guidelines, perform balloon tamponade in patients with uncontrolled bleeding but with a prerequisite of expertise and as a temporary "bridge" until definitive treatment can be instituted and for a maximum of 24 hours. B Consider placing removable, covered and self-expanding esophageal stents as an alternative to balloon tamponade. B As per ASGE 2014 guidelines, consider performing balloon tamponade when initial endoscopic therapy fails to control acute variceal hemorrhage, to temporarily control https://web.pathway.md/diseases/recplXN8m9B80jYmF 7/12 6/29/23, 3:23 AM Variceal hemorrhage Pathway bleeding until more definitive therapy can be performed. C Sengstaken-Blakemore tube: insert a Sengstaken-Blakemore tube if bleeding is difficult to control, until further endoscopic treatment, TIPS, or surgery is performed depending on local resources and expertise. B 7. Specific circumstances Patients with gastric varices, prevention of bleeding: As per EASL 2018 guidelines: Consider initiating nonselective -blockers for primary prevention of variceal hemorrhage from type 2 gastroesophageal varices or type 1 isolated gastric varices. C Follow the recommendations of esophageal varices for primary prevention of type 1 gastroesophageal varices. B As per AASLD 2017 guidelines, consider initiating nonselective -blockers for the prevention of first variceal hemorrhage from type 2 gastroesophageal varices or type 1 isolated gastric varices. E Show 2 more As per BSG 2015 guidelines, consider initiating nonselective -blockers for primary prophylaxis in selected high-risk patients with large gastroesophageal varices type 2 after taking into account the patient's preferences and clinical judgment. C Show 7 more Patients with gastric varices, management of bleeding: As per ESGE 2022 guidelines, administer cyanoacrylate injection for acute gastric (cardiofundal) variceal (gastroesophageal varices type 2, isolated gastric varices type 1) hemorrhage. A Show 2 more As per ALTA 2021 guidelines: Decide on the initial management of patients with bleeding gastric-fundal varices based on center expertise. Consider performing variceal obliteration/embolization with or without TIPS in patients with bleeding gastric-fundal varices if unable to be managed endoscopically. B Perform variceal obliteration with or without TIPS creation in patients with rebleeding gastric-fundal varices after endoscopic therapy. B As per EASL 2018 guidelines, treat acute gastric variceal hemorrhage medically similar to esophageal variceal hemorrhage. Use cyanoacrylate as the endoscopic hemostatic treatment for cardiofundal varices (gastroesophageal varices type 2 or isolated gastric varices type 1). B Show 2 more As per BSG 2015 guidelines, treat patients with gastroesophageal varices type 1 as for patients with esophageal varices. B Show 4 more As per ASGE 2014 guidelines: https://web.pathway.md/diseases/recplXN8m9B80jYmF 8/12 6/29/23, 3:23 AM Variceal hemorrhage Pathway Consider performing gastric variceal obturation with a cyanoacrylate-based compound for the treatment of acute gastric variceal hemorrhage at centers familiar with this technique. Otherwise, consider performing endoscopic variceal ligation. C Perform alternative interventions when gastric variceal hemorrhage cannot be controlled with endoscopic and pharmacological therapy. B Patients with compensated cirrhosis: aim to prevent the development of clinically significant portal hypertension and decompensated cirrhosis in patients with mild, compensated portal hypertension, rather than aiming to prevent the formation of varices. E Patients with hepatocellular carcinoma: apply the same principles for the prevention and treatment of acute variceal hemorrhage in patients with HCC, as for patients without HCC. E 8. Preventative measures Primary prevention: As per ESGE 2022 guidelines: Initiate nonselective -blockers (preferably carvedilol), if not contraindicated, to prevent the development of variceal bleeding in patients with compensated advanced chronic liver disease and clinically significant portal hypertension (hepatic venous pressure gradient > 10 mmHg and/or liver stiffness by transient elastography > 25 kPa). B Perform endoscopic band ligation as the endoscopic prophylactic treatment of choice in patients unable to receive nonselective -blocker therapy with high-risk esophageal varices on screening upper gastrointestinal endoscopy. Repeat endoscopic band ligation every 2-4 weeks until variceal eradication is achieved. Obtain surveillance upper gastrointestinal endoscopy every 3-6 months in the first year following eradication. B As per ALTA 2021 guidelines, insufficient evidence to recommend preoperative TIPS creation for the prevention of bleeding complications or the need for blood transfusion during or after invasive nontransplant surgical procedures in patients with portal hypertension requiring nontransplant surgery. I As per EASL 2018 guidelines, initiate primary prophylaxis upon detection of high-risk varices - small varices with red signs, medium or large varices irrespective of Child-Pugh classification, or small varices in Child-Pugh C patients - in patients with decompensated cirrhosis A , ascites, or an acute intercurrent condition. B Show 7 more As per AASLD 2017 guidelines: Initiate traditional nonselective -blockers (propranolol, nadolol), carvedilol, or perform endoscopic variceal ligation for the prevention of first variceal hemorrhage in patients with medium or large varices. E Avoid the combination of nonselective -blockers plus endoscopic variceal ligation for primary prophylaxis. D As per BSG 2015 guidelines, initiate primary prophylaxis in patients with grade I varices and red signs or grade 2-3 varices, irrespective of the severity of the liver disease. A Show 6 more https://web.pathway.md/diseases/recplXN8m9B80jYmF 9/12 6/29/23, 3:23 AM Variceal hemorrhage Pathway As per ASGE 2014 guidelines, perform endoscopic variceal ligation in patients with large esophageal varices unable to tolerate or having contraindications to nonselective -blockers. B Show 3 more Secondary prevention: As per ESGE 2022 guidelines: Perform follow-up endoscopic band ligations at 1- to 4-weekly intervals to eradicate esophageal varices (secondary prophylaxis) in patients undergone endoscopic band ligation for acute esophageal variceal hemorrhage. B Initiate nonselective -blockers (propranolol or carvedilol) in combination with endoscopic therapy for secondary prophylaxis in esophageal variceal hemorrhage in patients with advanced chronic liver disease. A As per EASL 2018 guidelines, attempt reinitiating nonselective -blockers after recovery from bleeding. B Manage the bleeding risk by expeditious endoscopic band ligation if nonselective -blocker intolerance or contraindications persist. B Show 2 more As per AASLD 2017 guidelines, administer nonselective -blockers combined with endoscopic variceal ligation as first-line therapy in patients with a history of variceal hemorrhage. E As per BSG 2015 guidelines, initiate nonselective -blockers (propranolol or nadolol) and variceal band ligation combination therapy for secondary prophylaxis in patients with variceal hemorrhage. A Show 9 more As per ASGE 2014 guidelines: Repeat endoscopy with endoscopic variceal ligation after treatment of the acute episode of variceal hemorrhage until varices have been eradicated. B Consider repeating endoscopy at 1- to 8-week intervals for endoscopic variceal ligation for secondary prophylaxis. C 9. Follow-up and surveillance Post-endoscopic hemostasis imaging: obtain cross-sectional imaging (magnetic resonance or CT) with portal venous contrast phase to determine vascular anatomy, including the presence or absence of portosystemic shunts and gastrorenal shunts, after initial endoscopic hemostasis. B Serial assessment of HVPG: avoid monitoring changes in hepatic venous pressure gradient routinely. Recognize that noninvasive tests do not correlate well with changes in hepatic venous pressure gradient. D Endoscopic surveillance: as per ASGE 2014 guidelines, obtain endoscopic surveillance every 3-6 months after endoscopic treatment of acute variceal hemorrhage. Treat recurrent varices with endoscopic variceal ligation. B Post-TIPS surveillance: https://web.pathway.md/diseases/recplXN8m9B80jYmF 10/12 6/29/23, 3:23 AM Variceal hemorrhage Pathway Obtain surveillance Doppler ultrasound 3 months after TIPS creation and every 6 months thereafter to monitor for post-TIPS stenosis or occlusion. B Consider obtaining TIPS venogram with pressure measurements with consideration of TIPS revision in patients with suspected TIPS stenosis/occlusion or rebleeding after TIPS creation. C Clinical findings Symptoms Past medical history Black, tarry, or bloody stool Portal hypertension Lightheadedness Hematological findings Vomiting of blood Anemia Vital signs Endoscopic findings Hypotension Signs of shock Red spot sign Red wale sign ECG findings Sinus tachycardia Studies 2020 HALT-IT In adult patients with significant (defined as at risk of bleeding to death) upper or lower gastrointestinal bleeding, tranexamic acid was not superior to placebo with respect to the rate of death due to bleeding within 5 days. HALT-IT Trial Collaborators. Lancet. 2020 Jun 20. 2020 Timing of endoscopy for AUGB In patients with overt signs of acute upper gastrointestinal bleeding and a Glasgow-Blatchford score 12, urgent-endoscopy was not superior to early-endoscopy with respect to death from any cause at 30 days. James Y W Lau et al. N Engl J Med. 2020 Apr 2. Show 4 more References 1. Garcia-Tsao G, Abraldes JG, Berzigotti A et al. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology. 2017 Jan;65 1 310 335. Open https://web.pathway.md/diseases/recplXN8m9B80jYmF 11/12 6/29/23, 3:23 AM Variceal hemorrhage Pathway 2. Dhiraj Tripathi, Adrian J Stanley, Peter C Hayes et al. U.K. guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut. 2015 Nov;64 11 1680 704. Open 3. Joo Ha Hwang, Amandeep K Shergill, Ruben D Acosta et al. The role of endoscopy in the management of variceal hemorrhage. Gastrointest Endosc. 2014 Aug;80 2 221 7. Open 4. Ian M Gralnek, Marine Camus Duboc, Juan Carlos Garcia-Pagan et al. Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy ESGE Guideline. Endoscopy. 2022 Sep 29. Open 5. European Association for the Study of the Liver. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol. 2018 Aug;69 2 406 460. Open 6. Zachary Henry, Kalpesh Patel, Heather Patton et al. AGA Clinical Practice Update on Management of Bleeding Gastric Varices: Expert Review. Clin Gastroenterol Hepatol. 2021 Jun;19 6 1098 1107.e1. Open 7. Justin R Boike, Bartley G Thornburg, Sumeet K Asrani et al. North American Practice-Based Recommendations for Transjugular Intrahepatic Portosystemic Shunts in Portal Hypertension. Clin Gastroenterol Hepatol. 2021 Jul 15;S1542 3565 21 00749 7. Open 8. Simon J Stanworth, Kerry Dowling, Nikki Curry et al. A guideline for the haematological management of major haemorrhage: a British Society for Haematology Guideline. Br J Haematol. 2022 Jun 10. Open 9. de Franchis R, Baveno VI Faculty. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol. 2015 Sep;63 3 743 52. Open 10. Yong Lv, Zhiping Yang, Lei Liu et al. Early TIPS with covered stents versus standard treatment for acute variceal bleeding in patients with advanced cirrhosis: a randomised controlled trial. Lancet Gastroenterol Hepatol. 2019 Aug;4 8 587 598. Open 11. Expert Panels on Interventional Radiology and Vascular Imaging, Jason W Pinchot, Sanjeeva P Kalva et al. ACR Appropriateness Criteria Radiologic Management of Portal Hypertension. J Am Coll Radiol. 2021 May;18 5S S153 S173. Open 12. Tram T Tran, Joseph Ahn, Nancy S Reau. ACG Clinical Guideline: Liver Disease and Pregnancy. Am J Gastroenterol. 2016 Feb;111 2 176 94; quiz 196. Open 13. Monika Sarkar, Carla W Brady, Jaquelyn Fleckenstein et al. Reproductive Health and Liver Disease: Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021 Jan;73 1 318 365. Open 14. Rahul Nanchal, Ram Subramanian, Waleed Alhazzani et al. Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU Neurology, Peri-Transplant Medicine, Infectious Disease, and Gastroenterology Considerations. Crit Care Med. 2023 May 1;51 5 657 676. Open https://web.pathway.md/diseases/recplXN8m9B80jYmF 12/12