CASE 02•8–10 minutes•Variceal bleeding · TIPS · Haemorrhage · Portal hypertension

Variceal bleeding: when should TIPS happen?

A patient with cirrhosis presents with acute variceal haemorrhage. Work through resuscitation, pre-emptive TIPS and what to do if bleeding is not controlled.

For clinicians working in critical care, hepatology, gastroenterology and acute medicine.

Apply the early management bundle for suspected acute variceal bleeding.

Identify who should be considered for pre-emptive TIPS and distinguish this from salvage TIPS.

Avoid treating ACLF, encephalopathy or a high MELD score as automatic contraindications to pre-emptive TIPS.

Hour 0 · Emergency department

The bleed

Stage 1 of 5

Haematemesis, cirrhosis and shock.

A 58-year-old man with alcohol-related cirrhosis presents after two large episodes of haematemesis. He is pale and clammy. He is awake but drowsy, answering questions appropriately. There is no known coronary disease.

Two large-bore cannulae are in place. Cross-match has been sent and the major haemorrhage team has been alerted. The immediate question is what should happen before endoscopy.

BP88/52 mmHg

Heart rate116/min

Hb68 g/L

Platelets64 ×10⁹/L

INR1.8

Lactate4.3 mmol/L

Your decision

Which initial strategy best fits current guidance?

Choose an approach to reveal the discussion and supporting evidence.

Educational content only. The case is fictional and does not replace local guidance, specialist advice or individual clinical judgement.

Clinical review: Dr Tom Dixon · 2026-09-28

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