Key points
- Vomiting blood or black stools with known or suspected liver disease: go to the nearest hospital with an emergency and endoscopy service immediately.
- Treatment combines medicines that lower portal pressure (terlipressin or octreotide), antibiotics, careful blood transfusion and endoscopic banding, ideally within 12 hours.
- If bleeding cannot be controlled or returns, TIPS may be life-saving.
- After the bleed, beta-blockers plus repeat banding reduce the risk of bleeding again.
- A variceal bleed is a sign of advanced liver disease and a reason to be assessed for liver transplant.
If someone is vomiting blood right now
This is an emergency — act immediately
Take the person to the nearest hospital with an emergency department and endoscopy facility now, or call an ambulance. Go immediately for: vomiting fresh red blood or 'coffee-ground' material; black, tarry stools; dizziness or fainting; a racing pulse, cold sweaty skin or breathlessness; or confusion. Do not wait to see if it settles, and do not travel long distances to reach a particular hospital first — stabilisation comes first.
- 1
Keep them lying on their side
This protects the airway if they vomit again, especially if drowsy.
- 2
Nothing by mouth
No food, water or home remedies; an endoscopy will be needed.
- 3
Carry the details
Bring previous endoscopy reports, liver reports and a list of medicines — especially blood thinners, beta-blockers (propranolol, carvedilol) and painkillers.
- 4
Tell the hospital about liver disease
Saying 'known cirrhosis' or 'known varices' changes the first treatment given in the emergency room.
What varices are and why they bleed
In cirrhosis and other causes of portal hypertension, blood cannot flow easily through the liver. It finds detours through small veins at the lower end of the oesophagus (food pipe) and in the stomach. Under high pressure these veins swell into varices — thin-walled, like ballooned veins — and can burst. Oesophageal varices are the most common; gastric varices bleed less often but can bleed more heavily and are harder to treat.
Portal hypertension also occurs without cirrhosis — for example from a clot in the portal vein (extrahepatic portal vein obstruction, seen in young people in India) or non-cirrhotic portal fibrosis. In these patients the liver itself often works well, so treatment and outlook are different; see portal hypertension surgery.
Not all bleeding in liver patients is variceal. Peptic ulcers, especially after painkillers, are another important cause, and the endoscopy tells them apart.
What happens in hospital
| Treatment | What it does | When |
|---|---|---|
| Terlipressin or octreotide | Narrows the blood vessels feeding the portal system and lowers pressure in the varices | Started as soon as variceal bleeding is suspected, usually continued for 2–5 days |
| Antibiotics (commonly ceftriaxone) | Prevent infections, which are frequent after a bleed in cirrhosis and make re-bleeding and death more likely | From admission, for up to 7 days |
| Careful transfusion | Replaces lost blood; doctors deliberately avoid over-transfusing, which can raise portal pressure and restart bleeding | Usually when haemoglobin falls to about 7 g/dL |
| Endoscopic band ligation | Small rubber bands are placed around the varices through an endoscope to choke them off | Within 12 hours of arrival once the patient is stable |
| Glue injection | Used for bleeding gastric varices, which cannot be banded easily | At endoscopy, when gastric varices are the source |
Patients who are drowsy or bleeding heavily may need a breathing tube placed before endoscopy to protect the lungs. Lactulose is often started to prevent hepatic encephalopathy, because blood in the gut is a strong trigger for confusion.
When bleeding does not stop: balloon, stent and TIPS
In a minority of patients, bleeding continues or returns within days despite medicines and banding. A balloon tube or a special removable oesophageal stent can be used as a temporary bridge to hold pressure on the varices for up to a day or so.
TIPS (transjugular intrahepatic portosystemic shunt) is the definitive rescue: an interventional radiologist passes a stent through a neck vein into the liver, connecting the portal vein to a hepatic vein and lowering the pressure sharply. In selected high-risk patients, an early (pre-emptive) TIPS within about 72 hours of the bleed is recommended because it reduces re-bleeding and improves survival. TIPS can worsen encephalopathy, and it is chosen with the liver's function and future transplant in mind.
Preventing another bleed
Without prevention, a large proportion of people who survive a variceal bleed will bleed again within a year or two. Secondary prevention roughly halves that risk:
- Non-selective beta-blockers (propranolol or carvedilol), taken every day, at a dose adjusted to pulse and blood pressure. Do not stop them suddenly.
- Repeat banding every 2–4 weeks until the varices are eradicated, then surveillance endoscopy at intervals set by the doctor.
- Treating the cause: complete abstinence from alcohol, antiviral treatment for hepatitis B or C, weight and diabetes control in fatty liver disease.
- Avoiding NSAID painkillers such as diclofenac and ibuprofen, which increase the risk of bleeding and kidney injury.
Screening before a first bleed
Everyone diagnosed with cirrhosis should be checked for varices — by endoscopy, or in some patients by FibroScan and platelet count. Large varices found early can be treated with beta-blockers or banding before they ever bleed.
Why a bleed should prompt transplant assessment
In cirrhosis, a variceal bleed is a decompensating event: it shows the portal pressure is high and the liver disease is advanced. Many patients stabilise well after banding, but their long-term outlook depends on the liver, and each further bleed carries serious risk. Anyone with cirrhosis who has bled from varices should be referred for liver transplant evaluation, particularly if they also have ascites, jaundice or encephalopathy, or a high MELD score.
A liver transplant corrects portal hypertension at its root. Dr Bappaditya Har and the transplant team at Narayana RN Tagore Hospital, Mukundapur, Kolkata review endoscopy reports, scans and blood tests to advise on the timing — whether that means watchful follow-up, TIPS or surgery for portal hypertension, or a living donor liver transplant. Reports can be sent first on WhatsApp (+91 70420 39420); for active bleeding, go to the nearest emergency first.
Frequently asked questions
What does black stool mean in liver disease?
Black, tarry, foul-smelling stool (melaena) usually means bleeding from the upper gut, such as varices or an ulcer. In someone with liver disease it is an emergency. Iron tablets can also blacken stools, but these are usually formed and not sticky — if in doubt, go to hospital.
Can variceal bleeding stop on its own?
Bleeding sometimes pauses, but the risk of it returning heavily in the next few days is high. It must always be treated in hospital with medicines and endoscopy.
What is banding of varices?
Endoscopic band ligation places small rubber bands around the swollen veins through an endoscope. The banded vein clots and falls off over days. It is done in sessions a few weeks apart until the varices are gone.
Can a person live normally after a variceal bleed?
Many people recover well and return to normal activity, provided they take beta-blockers, complete banding and treat the cause of their liver disease. The bleed still means the liver disease is advanced, so regular follow-up and a transplant assessment are important.
Does TIPS cure variceal bleeding?
TIPS lowers portal pressure and is very effective at stopping and preventing variceal bleeding, but it does not treat the liver disease itself and can increase confusion. It is often a bridge to a transplant rather than a cure.
Do all cirrhosis patients need a liver transplant after a bleed?
Not all, but all should be assessed. The decision depends on liver function, other complications and overall health. Some patients stabilise for years with treatment; others need a transplant soon.
Related reading
Portal Hypertension Treatment and Surgery in Kolkata →
Portal hypertension from cirrhosis, EHPVO or NCPF: variceal bleeding, big spleen, and the treatment ladder from banding and TIPS to shunt surgery.
Liver Cirrhosis Treatment in Kolkata: Stages, Care and When to Consider a Transplant →
Cirrhosis explained: compensated vs decompensated, Child-Pugh and MELD in plain words, what treatment can and cannot do, and when to consider a transplant.
Liver Transplant Evaluation: Who Needs It, MELD Scores and the Tests →
Who needs a liver transplant, what MELD and PELD scores mean, the tests in a transplant work-up, reasons transplant may not be possible, and what to bring.
Hepatic Encephalopathy: Confusion and Drowsiness in Liver Disease →
Confusion, drowsiness or day-night reversal in liver disease may be hepatic encephalopathy. Learn triggers, lactulose, rifaximin, diet and urgent signs.
Signs and Symptoms of Liver Disease →
Liver disease is often silent until late. Learn the early and late warning signs, which symptoms are urgent, the simple tests, and who should get checked.
This page is general patient information, not a diagnosis or a substitute for a consultation. Treatment decisions depend on each patient's reports and examination. Read our medical disclaimer and editorial policy.