Summary : This flowchart outlines the recommended clinical management pathway for patients presenting with upper gastrointestinal bleeding, based on initial risk stratification using the Glasgow-Blatchford Score, pre-endoscopic management, and endoscopic findings. flowchart: # Nodes : • Initial risk stratification and triage (rectangle) – Very-Low Clinical Risk (rectangle) • Risk score indicates 0–1% false negatives for transfusion, hemostatic intervention, or death • Glasgow-Blatchford Score 0–1 – Not Very-Low Clinical Risk (rectangle) • Risk score indicates >1% false negatives for transfusion, hemostatic intervention, or death • Glasgow-Blatchford Score ≥2 – Discharge from emergency department with outpatient management if no other reason for hospitalization (rectangle) – Admit to hospital or observation unit (rectangle) • Pre-endoscopic management (rectangle) – Resuscitation, attention to active comorbidities – RBC transfusion if hemoglobin <7 g/dL – Suggest erythromycin 250mg infusion 30–90 minutes before upper endoscopy – No recommendation for or against proton pump inhibitors • Upper endoscopy within 24 hours of presentation (rectangle) • Endoscopy (rectangle) – Low-risk endoscopic findings (rectangle) • e.g., clean-based ulcer, nonbleeding Mallory-Weiss tear, erosions • Discharge patient if stable vital signs and hemoglobin, and no other reason for hospitalization – Non-low-risk endoscopic findings (rectangle) • e.g., ulcer with stigmata of hemorrhage, varices, neoplasm, Dieulafoy lesion • Patient remains in hospital # Connectors : • From "Initial risk stratification and triage" split into two branches: – Very-Low Clinical Risk → Discharge from emergency department – Not Very-Low Clinical Risk → Admit to hospital or observation unit • Both branches converge to "Pre-endoscopic management" • "Pre-endoscopic management" leads to "Upper endoscopy within 24 hours of presentation" • "Endoscopy" splits into: – Low-risk endoscopic findings → Discharge patient if stable – Non-low-risk endoscopic findings → Patient remains in hospital # Layout : • Vertical flow from top (Initial risk stratification) to bottom (Endoscopy outcomes) • Two main branches at the top (Very-Low vs Not Very-Low Clinical Risk) merge before pre-endoscopic management • Endoscopy results split into two outcome branches (discharge vs remain in hospital) # Analysis : • The flowchart provides a clear, stepwise approach for triaging and managing upper GI bleeding based on risk assessment and endoscopic findings. • Patients with very-low clinical risk (Glasgow-Blatchford Score 0–1) are discharged early, while higher-risk patients are admitted. • Pre-endoscopic management is standardized for all admitted patients, focusing on resuscitation and transfusion thresholds. • Endoscopic findings further stratify patients into those suitable for discharge versus those requiring continued hospitalization. • The process emphasizes early risk stratification and timely endoscopy (within 24 hours) to optimize patient outcomes.

Summary : This figure presents two flowcharts (A and B) outlining the management of acute variceal bleeding in patients with portal hypertension, with specific pathways for esophageal/GOV1 bleeding (A) and GOV2/IGV2 or ectopic varices (B). An inset illustration shows the Sarin Classification of Gastric Varices. flowchart: # (A) Management of Acute Variceal Bleeding: Esophageal and/or GOV1 Bleeding ## Nodes : • Acute gastrointestinal hemorrhage in patient with portal hypertension (rectangle) • Airway protection / Cardiovascular resuscitation (rectangle) • Restrictive transfusion, avoidance of FFP/platelet transfusion, vasoactive therapy, antimicrobial prophylaxis (rectangle) • Upper endoscopy within 12 hours (rectangle) • Bleeding esophageal or GOV1 varices (rectangle) • Esophageal Band Ligation (rectangle) • Hemostasis achieved? (diamond) • Yes (arrow label) • No (arrow label) • Balloon tamponade (Minnesota, Linton, or Sengstaken-Blakemore Tube) / Esophageal stent (rectangle) • Salvage TIPS (rectangle) • Bleeding GOV2/IGV or ectopic varices (rectangle) • GO TO FIGURE 5 (rectangle) • Bleeding Portal Hypertensive Gastropathy (rectangle) • CTP A-B7 or no active bleeding (rectangle) • Best supportive care / Transplant (rectangle) • CTP B8-9 with active bleeding or CTP C13 (rectangle) • Pre-emptive TIPS (rectangle) • Confirmation of varices (rectangle) • Non-portal hypertension cause (rectangle) • Discontinue vasoactive therapy (rectangle) • Supportive care, start NSBB, repeat endoscopic therapy until obliteration (rectangle) • Rebleeding (particularly within 6 weeks) (rectangle) • Consider attempt at repeat EBL (rectangle) • TIPS (rectangle) ## Connectors : • Arrows indicate stepwise progression, with decision diamonds for hemostasis and CTP score-based branches. • "Yes" and "No" branches from decision points. • Feedback loop from "Rebleeding" to "Consider attempt at repeat EBL" and then to "TIPS". ## Layout : • Top-down, left-to-right branching. • Parallel tracks for esophageal/GOV1 vs. GOV2/IGV/ectopic varices. • Decision points (diamonds) split into multiple management options. # (B) Management of Acute Variceal Bleeding: GOV2/IGV2 or Ectopic Varices ## Nodes : • Bleeding GOV2/IGV or ectopic varices (rectangle) • Vascular Imaging if stable (rectangle) • Local expertise in Endoscopic Cyanoacrylate Injection (diamond) • Yes (arrow label) • No (arrow label) • Endoscopic Cyanoacrylate Injection ± Endoscopic Coiling (rectangle) • Hemostasis achieved? (diamond) • Yes (arrow label) • No (arrow label) • Supportive care, start NSBB, repeat endoscopic therapy until obliteration (rectangle) • Rebleeding (particularly within 6 weeks) (rectangle) • Pre-emptive TIPS (rectangle) • Best supportive care / Transplant (rectangle) • CTP C13 or CTP B8-9 with active bleeding (rectangle) • CTP A-B7 or no active bleeding (rectangle) • Vascular imaging (contrast CT, MRI with gadolinium, Doppler US) (rectangle) • TIPS ± Variceal obliteration (e.g., BRTO) (rectangle) • Variceal obliteration (e.g., BRTO, BATO, CARTO) (rectangle) • Splenectomy, pSAE, splenic vein stenting (rectangle) • Consider Balloon Tamponade (Linton-Nachlas or Minnesota) (rectangle) ## Connectors : • Arrows indicate stepwise progression, with decision diamonds for local expertise and hemostasis. • "Yes" and "No" branches from decision points. • Feedback loop from "Rebleeding" to "Pre-emptive TIPS". ## Layout : • Top-down, left-to-right branching. • Decision points (diamonds) split into multiple management options. • Parallel tracks for endoscopic vs. radiologic interventions. # Sarin Classification of Gastric Varices (Inset Illustration) ## Scene Overview : • Anatomical illustration of the stomach with labeled varices: EV (esophageal varices), GOV1, GOV2, IGV1, IGV2. • GOV1: along the lesser curvature. • GOV2: along the fundus and greater curvature. • IGV1: isolated gastric varices in the fundus. • IGV2: isolated gastric varices elsewhere. ## Technical Details : • Colour illustration with labels directly on the stomach anatomy. • No scale bar or magnification. # Analysis : • The flowcharts provide a structured, algorithmic approach to managing acute variceal bleeding, with early endoscopy and decision points based on variceal location, hemostasis, and Child-Turcotte-Pugh (CTP) score. • For esophageal/GOV1 bleeding, endoscopic band ligation is first-line, with escalation to balloon tamponade or TIPS if hemostasis fails. • For GOV2/IGV2/ectopic varices, endoscopic cyanoacrylate injection is preferred if expertise is available, otherwise radiologic interventions are considered. • Both pathways emphasize supportive care, repeat interventions for rebleeding, and consideration of transplant in advanced cases. • The Sarin Classification inset clarifies anatomical distinctions relevant to the management algorithms.

Summary : This flowchart provides a decision-making algorithm for managing patients with cardiac stents who are receiving dual antiplatelet therapy (DAPT) and are scheduled for interventional radiology (IR) procedures, focusing on bleeding risk and peri-procedural antiplatelet management. flowchart: # Nodes : • Start (rectangle): "Patient with cardiac* stent who is receiving DAPT and is scheduled for IR procedure" • Decision (rectangle): "Can this procedure be done on DAPT?" • Branch 1 (rectangle, green): "YES - Planned procedure has low risk of bleeding" • Branch 2 (rectangle, red): "No - Planned procedure has high risk of bleeding" • Action (rectangle, green): "Continue current DAPT" • Decision (diamond): "Stent placed < 1 year" • Branch 2a (rectangle, red): "Consult cardiology, or vascular or internal medicine for management recommendations" • Branch 2b (rectangle, green): 1. "Continue ASA" 2. "May hold second antiplatelet agent for 5 days before procedure" 3. "Consider consult to cardiology, vascular or internal medicine for management recommendations" • End (rectangle): "PROCEDURE" # Connectors : • Downward arrows from start node to decision node. • Decision node splits into two branches: – Left arrow to "YES - Planned procedure has low risk of bleeding" → downward arrow to "Continue current DAPT" → downward arrow to "PROCEDURE". – Right arrow to "No - Planned procedure has high risk of bleeding" → downward arrow to diamond "Stent placed < 1 year". • If YES: rightward arrow to "Consult cardiology, or vascular or internal medicine for management recommendations" → downward arrow to "PROCEDURE". • If NO: downward arrow to green box with 3 steps → downward arrow to "PROCEDURE". # Layout : • Horizontal split after the main decision node ("Can this procedure be done on DAPT?") into two branches (low risk vs. high risk). • Right branch includes a further decision diamond ("Stent placed < 1 year") with two possible outcomes. • All branches ultimately converge on the final "PROCEDURE" node. # Analysis : • The flowchart provides a clear, stepwise approach for peri-procedural management of DAPT in patients with cardiac stents, prioritising bleeding risk and stent age. • For low bleeding risk procedures, DAPT is continued. • For high bleeding risk procedures, stent age determines whether specialist consultation is required or if ASA can be continued with temporary cessation of the second agent. • The algorithm ensures patient safety by balancing thrombosis and bleeding risks, and recommends specialist input for complex cases.