Epistaxis Algorithm · Reasoning GP

Safety

Red Flags — Massive haemorrhage, blood dyscrasias, malignancy

Done

Urgent exclusion of life-threatening bleeding and serious underlying pathology.

Massive ongoing bleeding Profuse blood loss, haemodynamic compromise (hypotension, tachycardia), pallor, dizziness → 999 or immediate A&E (posterior bleed, arterial source)

Uncontrolled despite 30 mins pressure Continuous bleeding after proper first aid (pinch soft part, lean forward) → Same-day ENT or A&E (packing/cautery needed)

Recurrent bilateral bleeds Both nostrils bleeding simultaneously or alternating frequently → Urgent ENT (hereditary haemorrhagic telangiectasia, systemic cause)

Easy bruising / petechiae Spontaneous bruising, petechial rash, bleeding gums, menorrhagia → Urgent bloods FBC, clotting (thrombocytopenia, leukaemia, coagulopathy)

Anticoagulation + uncontrolled bleed Warfarin/DOAC/aspirin with epistaxis not stopping → Same-day assessment, check INR, reverse if supratherapeutic

Unilateral + nasal obstruction One-sided bleeds, blocked nose, facial pain/swelling, cranial nerve signs → 2WW ENT (nasal tumour, sinonasal malignancy)

Child <2 years with epistaxis Uncommon age for nosebleeds → Investigate (blood dyscrasia, NAI, foreign body, tumour rare)

Posterior bleed features Blood down throat, choking, coughing up blood, bleeding from both nostrils → A&E (posterior nasal packing needed)

Posterior epistaxis is a medical emergency — bleeding from sphenopalatine or ethmoidal arteries, difficult to control with simple pressure. Blood flows down throat (patient swallows/vomits blood). Requires ENT packing or interventional radiology (arterial embolisation). Can cause airway obstruction or aspiration.

Massive haemorrhage (>1 litre blood loss) causes hypovolaemic shock. Elderly patients on anticoagulants are highest risk. Requires IV access, resuscitation, transfusion, urgent ENT/interventional radiology. Death from epistaxis is rare but occurs (40 deaths/year UK, mostly elderly anticoagulated patients).

Unilateral bleeds with obstruction = nasal malignancy until proven otherwise. Squamous cell carcinoma, adenoid cystic carcinoma, melanoma all present with unilateral bleeding + obstruction. Delay = advanced disease, poor prognosis. 2WW referral mandatory.

Diagnose

History — Frequency, severity, triggers, medications

Done

Take detailed history focusing on bleeding pattern, volume, triggers, and underlying risk factors.

Bleeding characteristics

Frequency: First episode vs recurrent (daily, weekly, monthly). Laterality: One nostril (anterior) vs both/alternating (posterior or systemic). Duration: Seconds vs minutes vs hours. Volume: Drops vs tablespoons vs cups (quantify).

First aid attempted

Correct technique: Sit forward, pinch soft part of nose (not bridge), 10-15 minutes continuous pressure. Incorrect: Lying back (swallows blood, nauseates), ice on bridge (ineffective), head between knees. Ask what patient did — incorrect technique = not truly refractory bleed.

Triggers

Local: Nose picking, trauma, nose blowing, dry air (winter heating, air conditioning), intranasal drugs (cocaine, steroid sprays). Systemic: Straining, coughing, hot showers, alcohol. Iatrogenic: Recent nasal surgery, cautery, packing removal.

Medications

Anticoagulants: Warfarin, DOACs (apixaban, rivaroxaban, edoxaban, dabigatran), aspirin, clopidogrel. NSAIDs: Ibuprofen, naproxen (impair platelet function). Nasal sprays: Steroid sprays (thinning septum), decongestants (rebound vasodilation). Herbal: Ginkgo, ginseng, fish oils (antiplatelet).

Bleeding elsewhere

Easy bruising, bleeding gums, heavy periods, PR bleeding, haematuria, haemoptysis. Presence = systemic bleeding disorder (coagulopathy, thrombocytopenia, platelet dysfunction). Absence = local nasal cause.

PMH

Hypertension (posterior epistaxis), liver disease (coagulopathy), renal failure (platelet dysfunction, uraemia), hereditary haemorrhagic telangiectasia (HHT — family history of nosebleeds + telangiectasia).

Age pattern

Children (2-10 years): Common, anterior, self-limiting (Little's area trauma). Young adults: Rare unless trauma, cocaine. Elderly (>60 years): Posterior bleeds, anticoagulation, hypertension. Bimodal distribution.

Correct first aid technique is critical — 90% of anterior nosebleeds stop with proper pressure (pinch soft part 10-15 minutes). Many "refractory" bleeds are actually inadequate pressure (pinching bony bridge, insufficient duration, looking up to check bleeding = releasing pressure). Education on technique prevents ED attendances.

Anticoagulation increases bleeding risk 2-3 fold but is rarely sole cause of epistaxis. Nosebleed in anticoagulated patient = identify bleeding site (usually Little's area), control bleed, check INR (reverse if supratherapeutic), but do NOT routinely stop anticoagulation (thrombotic risk > bleeding risk).

Bilateral bleeding suggests systemic cause — coagulopathy, thrombocytopenia, or posterior source. Unilateral bleeding suggests local pathology (Little's area trauma, tumour, vascular malformation). Laterality directs investigation.

Diagnose

Classification — Anterior vs Posterior, primary vs secondary

Done

Classify based on anatomical site and underlying cause. Determines management urgency.

Anterior epistaxis

Site: Little's area (Kiesselbach's plexus) — anterior inferior septum where 5 arteries anastomose. Features: Unilateral, visible bleeding from one nostril, stops with pressure. Prevalence: 90% of epistaxis. Cause: Trauma (nose picking, dry air, nose blowing). Benign, self-limiting

Posterior epistaxis

Site: Sphenopalatine artery, ethmoidal arteries (posterior nasal cavity). Features: Bilateral bleeding, blood down throat, difficult to see source, does NOT stop with pressure. Prevalence: 10% of epistaxis. Risk: Elderly, hypertensive, anticoagulated. Medical emergency

Primary (idiopathic)

No underlying cause identified. Local vascular fragility at Little's area. Prevalence: 85% of cases. Management: Conservative (pressure, cautery if recurrent). Prognosis: Excellent, self-limiting, outgrown in children by adolescence.

Secondary epistaxis

Underlying systemic cause: Anticoagulation, hypertension, bleeding disorder, liver disease, malignancy. Prevalence: 15% of cases. Investigation: FBC, clotting, BP, examination. Management: Treat underlying cause + local measures.

HHT (Osler-Weber-Rendu)

Hereditary Haemorrhagic Telangiectasia. Autosomal dominant. Features: Recurrent epistaxis from childhood, telangiectasia (lips, tongue, fingers), AVM (pulmonary, cerebral, hepatic). Diagnosis: Curaçao criteria. Management: Specialist centre, laser, bevacizumab.

Trauma-related

Iatrogenic: Nasal surgery, septoplasty, cautery. External: Facial fracture, assault, RTA. Chemical: Cocaine (septal perforation), intranasal steroids (chronic use). Mechanical: NG tube, nasal CPAP.

Anterior vs posterior distinction is critical — determines management site (home vs hospital). Anterior bleeds managed in primary care with pressure ± cautery. Posterior bleeds require ENT packing or interventional radiology in hospital. Missing posterior bleed = massive haemorrhage, aspiration, death.

Primary epistaxis is diagnosis of exclusion — only diagnosed after excluding systemic causes (anticoagulation, blood dyscrasia, hypertension, malignancy). Young healthy patient with unilateral bleeding = likely primary. Elderly patient on warfarin with bilateral bleeding = secondary until proven otherwise.

HHT prevalence 1 in 5000 — underdiagnosed. Think of HHT in anyone with recurrent epistaxis starting in childhood. Curaçao criteria (need 3 of 4): epistaxis, telangiectasia, visceral AVMs, family history. Diagnosis important because pulmonary AVMs cause stroke risk (paradoxical embolism) — treatable with coil embolisation.

Diagnose

Examination — Inspect nose, check BP, look for bleeding disorder

Done

Examine during or immediately after bleeding if possible. Focus on identifying bleeding site and systemic signs.

Vital signs

BP both arms (hypertension = posterior bleed risk), pulse (tachycardia if significant blood loss), temperature (rarely elevated unless sinusitis/infection). Postural BP if suspecting volume depletion (elderly, prolonged bleeding).

Nasal inspection

External: Trauma, deformity, swelling, erythema. Anterior rhinoscopy: Use Thudichum speculum + headlight (or smartphone torch). Inspect Little's area (anterior septum) for visible vessel, clot, perforation. Blood clot removal: Gently blow nose to clear clot and identify bleeding point.

Bleeding site

Visible anterior source: Little's area (90%) — prominent vessel, fresh blood, unilateral. Posterior: Blood in nasopharynx (examine oropharynx — blood trickling down posterior wall). No visible source: Stopped bleeding or posterior (refer ENT for nasoendoscopy).

Septal abnormalities

Septal perforation (cocaine, chronic steroid spray, Wegener's granulomatosis), deviation (predisposes to dryness on convex side), crusting (atrophic rhinitis, Wegener's), telangiectasia (HHT — also check lips, tongue).

Signs of bleeding disorder

Petechiae (thrombocytopenia), purpura, bruising (easy bruising, multiple sites), pallor (anaemia from chronic blood loss), jaundice (liver disease coagulopathy), splenomegaly (portal hypertension, haematological malignancy).

HHT screening

Telangiectasia on: lips, oral mucosa, tongue, fingers, nail beds. If present + recurrent epistaxis + family history = HHT likely. Screen for visceral AVMs (pulmonary, cerebral, hepatic) with imaging.

Facial examination

Unilateral facial swelling, proptosis, cranial nerve palsies (sinonasal malignancy). Facial numbness (infraorbital nerve compression). Lymphadenopathy (cervical nodes — malignancy).

Identifying bleeding site enables targeted cautery — silver nitrate stick applied to visible vessel at Little's area stops 95% recurrent anterior bleeds. Blind cautery without identifying site is ineffective and risks septal perforation. If site not visible, ENT nasoendoscopy needed.

Hypertension does NOT cause epistaxis directly but worsens bleeding once started (higher arterial pressure = harder to achieve haemostasis). Posterior bleeds are more common in hypertensives (atherosclerotic vessel fragility). Do NOT aggressively lower BP during acute bleed (impairs clot formation) — control after bleeding stopped.

Septal perforation causes: cocaine (vasoconstriction → ischaemic necrosis), chronic intranasal steroid misuse (spray aimed at septum not turbinates), Wegener's granulomatosis (ANCA-associated vasculitis), trauma (repeated cautery). Large perforations whistle, crust, bleed recurrently.

Diagnose

Investigations — Selective testing if red flags or recurrent

Done

Investigate if: recurrent bleeds, bleeding elsewhere, anticoagulated, red flags, or first bleed age >60 years.

FBC

Indications: Recurrent bleeds, easy bruising, petechiae, pallor, suspected anaemia from chronic blood loss. Check for: Hb (anaemia), platelets <50 (thrombocytopenia), WCC (leukaemia). Normal FBC does NOT exclude bleeding disorder (platelet function defects have normal count).

Clotting screen

Indications: On warfarin (check INR), liver disease, bleeding elsewhere, easy bruising, family history bleeding disorder. Tests: PT/INR, APTT. Prolonged APTT = haemophilia, von Willebrand disease (refer haematology). Prolonged PT = warfarin, liver disease, vitamin K deficiency.

Blood pressure

Always check in adults age >40 years or recurrent posterior bleeds. Hypertension found in 50% posterior epistaxis (unclear if cause or consequence). Treat hypertension AFTER bleeding controlled.

Nasoendoscopy

Indications: Recurrent unilateral bleeds, no visible anterior source, suspected posterior bleed, unilateral obstruction, suspected malignancy. Performed by: ENT. Findings: Posterior bleeding point, tumour, polyp, AVM. NOT routine in simple anterior epistaxis.

CT/MRI sinuses

Indications: Suspected sinonasal malignancy (unilateral obstruction, facial swelling, cranial nerve signs), recurrent bleeds with negative nasoendoscopy. Arranged by: ENT. NOT primary care.

Do NOT investigate

Single anterior bleed in child/young adult with no red flags, normal examination, stopped with pressure. Benign self-limiting — reassure, teach first aid, Naseptin cream. Over-investigation causes anxiety.

FBC and clotting find bleeding disorders in <5% of epistaxis patients. Reserve for those with clinical features suggesting systemic cause (easy bruising, petechiae, bleeding gums, family history). Routine testing in healthy children with single nosebleed is low yield and unnecessary.

INR monitoring in warfarin patients — target INR 2-3 for most indications. INR >4 increases bleeding risk 5-fold. Supratherapeutic INR + epistaxis = withhold warfarin 1-2 doses, recheck INR, restart when <3.5. If INR >8 or uncontrolled bleeding = vitamin K 1-2 mg PO. Do NOT routinely stop warfarin (stroke risk > bleeding risk).

Nasoendoscopy is gold standard for visualising entire nasal cavity and nasopharynx. Identifies posterior bleeding points, tumours, AVMs not visible on anterior rhinoscopy. Flexible scope passed via nostril under local anaesthetic (co-phenylcaine spray). ENT procedure, not primary care.

Refer

Referral Criteria — When to escalate urgently

Done

Refer all posterior bleeds, uncontrolled anterior bleeds, and red flag features.

999 / A&E

Massive ongoing bleeding (haemodynamic compromise). Posterior bleed (blood down throat, bilateral). Uncontrolled after 30 mins pressure. Anticoagulated + profuse bleed. Requires IV access, packing, possible embolisation.

2WW ENT

Unilateral obstruction + bleeding (nasal tumour suspected). Cranial nerve signs, facial swelling. Recurrent unilateral bleeds age >40 years with no anterior source visible. Unexplained epistaxis in child <2 years (rare, warrants investigation).

Urgent ENT

Recurrent bleeds despite cautery. No anterior source visible (needs nasoendoscopy). Suspected HHT (multiple telangiectasia + family history). Septal perforation enlarging or symptomatic.

Haematology

Thrombocytopenia (platelets <50). Prolonged APTT (haemophilia, vWD). Easy bruising + bleeding elsewhere. Family history bleeding disorder. Recurrent epistaxis + normal ENT assessment (platelet function disorder).

Primary care

Simple anterior epistaxis controlled with pressure. Visible Little's area source → cautery in practice. Recurrent but controllable → Naseptin BD 10 days. Child with self-limiting bleeds → reassure, teach first aid.

Posterior epistaxis requires hospital admission — cannot be controlled with simple pressure. Requires ENT packing (anterior + posterior packs, or Foley catheter balloon tamponade), or interventional radiology (sphenopalatine artery embolisation). 10-15% of admissions require embolisation. Delay = massive blood loss, aspiration, death.

Unilateral symptoms = malignancy until proven otherwise. Squamous cell carcinoma, adenocarcinoma, esthesioneuroblastoma all present with unilateral bleeding + obstruction. 2WW nasoendoscopy + biopsy. 5-year survival 60% if early, <20% if advanced. Delay = metastasis.

Most anterior bleeds managed in primary care — 90% stop with pressure, 95% of recurrent bleeds resolve with silver nitrate cautery. Only refer if: no visible source (needs nasoendoscopy), recurrent despite cautery (may need diathermy/laser), or red flags. Unnecessary ENT referrals burden limited capacity.

Treat

Acute Management — Pressure, packing, cautery

Done

Stop bleeding with first aid, then prevent recurrence with cautery or topical treatments.

Active bleeding (first aid)

Pressure technique First-line

Sit forward (not back). Pinch soft part of nose (not bony bridge) continuously 10-15 mins. Breathe through mouth. Spit blood, do NOT swallow. Ice pack on forehead/nose (vasoconstriction). If continues → A&E.

Recurrent anterior bleeds

Silver nitrate cautery In-practice

Identify bleeding point (Little's area). Local anaesthetic (co-phenylcaine spray 5 mins). Silver nitrate stick applied to vessel 3-5 seconds. Cauterise ONE side only (bilateral = perforation risk). 95% success rate.

Unable to cauterise / no visible source

Nasal packing Secondary care

Merocel (expandable sponge), Rapid Rhino (inflatable balloon). Insert along nasal floor, inflate/expand with saline. Remove after 24-48 hours. Requires admission if bilateral or posterior. Prophylactic co-amoxiclav (toxic shock syndrome risk).

Step 1Pressure 10-15 minutes — First aid for all epistaxis. Stops 90% anterior bleeds. Pinch soft part (below bony bridge), sit forward, continuous pressure. Do NOT release to check bleeding before 10 minutes elapsed.

Step 2Topical vasoconstrictor — If pressure fails: soak cotton wool in adrenaline 1:1000 or cocaine 5% (if available), insert into nostril, pinch 10 minutes. Co-phenylcaine spray (lidocaine 5% + phenylephrine 0.5%) alternative. ENT/A&E procedure.

Step 3Silver nitrate cautery — For recurrent bleeds with visible anterior source. Local anaesthetic first (co-phenylcaine spray 5 mins). Apply stick to bleeding point 3-5 seconds. Warn: black eschar forms, falls off in 7-10 days. Cauterise ONE side only.

Step 4Nasal packing — If cautery fails or no visible source. Merocel or Rapid Rhino. Remove 24-48 hrs. Antibiotics (co-amoxiclav 500/125 TDS) to prevent toxic shock. ENT/A&E procedure.

Step 5Interventional radiology — If packing fails. Sphenopalatine artery embolisation under fluoroscopy. 90% success rate. Reserved for severe recurrent posterior bleeds. Complications: facial numbness, palatal necrosis (rare).

Cautery technique

Indications: Visible bleeding point, recurrent epistaxis from same site. Contraindications: Active bleeding (apply pressure first), both sides at same session (perforation risk), child <10 years (poor tolerance). Method: Co-phenylcaine spray 5 mins, silver nitrate stick to vessel 3-5 seconds, avoid excessive cautery.

Anticoagulation

Do NOT routinely stop. Stroke/PE risk > bleeding risk. Warfarin: Check INR. If supratherapeutic (>4) → withhold 1-2 doses, recheck. If >8 or uncontrolled bleed → Vitamin K 1-2 mg PO. DOACs: Withhold 1 dose if ongoing bleed, resume when controlled. Discuss with anticoagulation team.

Tranexamic acid

Not routinely recommended for epistaxis (NICE). Some ENT units use: Tranexamic acid 1g TDS PO for 5 days in recurrent bleeds. Antifibrinolytic, stabilises clots. Evidence weak. Avoid if history VTE.

Pinching soft part of nose compresses Little's area (anterior inferior septum where 90% bleeds originate). Pinching bony bridge does nothing — no vessels there. Forward-leaning position prevents blood swallowing (causes nausea, obscures volume assessment). 15 minutes continuous pressure allows platelet plug formation.

Silver nitrate cautery is highly effective (95% success) when bleeding point visible. Chemical cauterisation coagulates vessel and surrounding tissue, seals bleeding point. Bilateral cautery risks septal perforation (devascularisation → ischaemic necrosis). Wait 6 weeks before cauterising opposite side if needed.

Stopping anticoagulation is harmful — stroke risk in AF patient off warfarin is 5%/year. Epistaxis in anticoagulated patient warrants investigation (identify source, cautery), INR check (reverse if supratherapeutic), but NOT routine cessation. Discuss with cardiologist before stopping DOACs/warfarin long-term.

Lifestyle

Prevention — Humidification, Naseptin, avoid triggers

Done

Prevent recurrence by moisturising nasal mucosa, avoiding trauma, and managing environmental factors.

Naseptin cream Apply pea-sized amount inside nostrils with little finger BD for 10 days. Contains chlorhexidine + neomycin (antibacterial) and moisturises septum. Prevents crusting, reduces S. aureus colonisation. CONTRAINDICATED if peanut/soya allergy (contains arachis oil).

Alternative: Bactroban nasal If Naseptin contraindicated (nut allergy). Mupirocin 2% nasal ointment BD 10 days. Antibacterial + emollient. Or simple petroleum jelly (Vaseline) TDS — cheaper, equally effective for moisturisation.

Saline nasal spray Sodium chloride 0.9% spray TDS-QDS. Keeps mucosa moist, prevents crusting, thins secretions. Available OTC (Sterimar, Neilmed). Use especially in winter (dry heated air) and air-conditioned environments.

Humidify air Bedroom humidifier (keep humidity 40-50%). Bowl of water on radiator. Prevents nasal mucosa drying overnight. Particularly important in winter (central heating), air-conditioned offices, low-humidity climates.

Avoid nose picking Main cause of recurrent childhood epistaxis. Trim fingernails short (reduces trauma). Distraction techniques for children. Address underlying cause (allergic rhinitis → itchy nose → picking).

Gentle nose blowing Blow gently, one nostril at a time. Vigorous blowing dislodges clots, increases pressure. Avoid forceful sniffing (can restart bleeding). Use tissues, not handkerchiefs (harbour bacteria).

Treat allergic rhinitis If sneezing/itching triggers bleeds. Intranasal steroid (mometasone, fluticasone) — aim spray AWAY from septum toward turbinates (prevents septal thinning). Antihistamines (cetirizine 10 mg OD) reduce sneezing.

Avoid triggers Hot showers (vasodilation), alcohol (vasodilation), straining, heavy lifting, bending forward. NSAIDs/aspirin if possible (impair platelet function). Cocaine (vasoconstriction → ischaemia → perforation).

Hydration Drink 2 litres water daily. Systemic hydration maintains nasal mucosa moisture. Dehydration thickens mucus, promotes crusting and bleeding.

First aid education Teach patient/parents correct technique: sit forward, pinch soft part, 15 minutes continuous pressure, do NOT tilt head back, do NOT release pressure early to check. Downloadable NHS leaflet available.

Naseptin reduces recurrence 70% in studies — antibacterial (chlorhexidine + neomycin) eradicates S. aureus (found in 60% recurrent epistaxis patients), while emollient base moisturises fragile mucosa. 10-day course sufficient. Longer use risks resistance. Peanut allergy contraindication because contains arachis (peanut) oil.

Humidification prevents drying — nasal mucosa needs 40-50% humidity. Winter central heating drops humidity to 20-30%, drying mucosa, causing crusting, cracking, bleeding. Bedroom humidifier or bowl of water on radiator restores physiological humidity. Simple, cheap, effective.

Correct steroid spray technique prevents iatrogenic epistaxis — aim spray AWAY from septum (toward outer wall/turbinates). Spraying directly at septum causes chemical thinning, ulceration, perforation, recurrent bleeding. Right hand for left nostril, left hand for right nostril achieves correct angle.

Safety

Follow-Up — Monitor recurrence, review anticoagulation, re-refer if red flags

Done

Schedule reviews based on severity. Safety-net for recurrent or severe bleeding.

1 week post-cautery

Phone review: Check eschar healing (falls off 7-10 days), no re-bleeding, Naseptin compliance. If re-bled → examine, re-cauterise if source visible, or refer ENT if no source.

2 weeks (if on Naseptin)

Review after 10-day Naseptin course. Check bleeding stopped, mucosa healed. If recurrent despite Naseptin → refer ENT (may need diathermy cautery or nasoendoscopy to identify source).

1 month (anticoagulated)

Check INR if on warfarin (ensure therapeutic 2-3). Review need for anticoagulation with patient (stroke risk vs bleeding risk). If recurrent bleeds on anticoagulation → consider alternative (DOAC may have lower bleeding risk than warfarin, though evidence mixed).

3 months (recurrent bleeds)

Review bleeding diary: Frequency, severity, triggers. If >1 bleed/month despite preventive measures → ENT referral for nasoendoscopy ± diathermy cautery. If HHT suspected → genetics referral.

Safety-net 999

Massive bleeding (soaking towels, blood clots size of fist). Haemodynamic compromise (dizziness, collapse, chest pain). Choking on blood (posterior bleed). Bleeding uncontrolled after 30 minutes proper pressure.

Safety-net Same-day GP

Recurrent bleeding (>3 episodes/week). Bleeding despite cautery. New unilateral symptoms (obstruction, facial pain). Easy bruising or petechiae develop. Pallor, fatigue (anaemia from chronic blood loss).

Re-refer ENT if

Recurrent bleeds despite cautery + Naseptin. New unilateral obstruction. Suspected malignancy. No anterior source identified (needs nasoendoscopy). Septal perforation enlarging or symptomatic (whistling, crusting).

Post-cautery follow-up ensures healing and identifies treatment failure. Silver nitrate creates black eschar (coagulated tissue) which falls off in 7-10 days, revealing healed pink mucosa underneath. If re-bleeding occurs = either incomplete cautery (missed bleeding point) or new bleeding site. Re-examine and re-cauterise if source visible.

Chronic blood loss causes iron-deficiency anaemia — even small frequent nosebleeds (teaspoon daily) = 5-10ml/day = 150-300ml/month. Check FBC if >4 weeks recurrent bleeds. Treat with ferrous sulphate 200mg BD, but also identify and treat bleeding source (cautery, Naseptin).

HHT requires specialist centre input — not managed in primary care. Screen for visceral AVMs (pulmonary with bubble echo, cerebral with MRI brain, hepatic with USS liver). Pulmonary AVMs cause paradoxical emboli (stroke risk 30% lifetime) — treatable with coil embolisation. Bevacizumab (anti-VEGF) reduces epistaxis severity in severe HHT.