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Introduction Acute variceal bleeding (AVB) carries high mortality risk. Prompt recognition and evidence-based management significantly improves outcomes. We evaluated local adherence to AVB guidelines (NICE NG50, BSG, ESGE, BAVENO VII 2021). At the time of this audit, the 2007 UK-wide Acute Upper Gastrointestinal Bleeding (AUGIB) audit and the Acute variceal haemorrhage in the United Kingdom: nationwide audit provided benchmarks. With the UK 2022 comparative audit of AUGIB published shortly after our audit in October 2025, local performance was benchmarked against both to identify strengths and areas for improvement. Pre-emptive transjugular intrahepatic portosystemic shunt (TIPSS) was formally incorporated in 2015- BAVENO VI. This audit sought to evaluate its consideration in clinical practice a decade after its inclusion in guidelines.Methods We conducted a retrospective, single centre audit of 642 patients presenting to Norfolk and Norwich University Hospital with suspected AUGIB between 01/10/2024 to 30/09/2025. 72 patients had varices/portal hypertensive gastropathy on endoscopy. We audited consideration of pre-emptive TIPSS. Re-bleed and in-hospital mortality rate were benchmarked against the 2007 and 2022 audits. Eight indicators were analysed for compliance with guideline recommendations. For each indicator, the expected achievement rate was 100%.Results 90.3% of patients had cirrhosis, most commonly alcohol related (58.4%). 68.5% required endotherapy. In-hospital mortality (10.2%) and re-bleeding rate (20.4%) was lower than national rates in 2007 (15% and 26% respectively). The 2022 UK AUGIB audit does not provide specific re-bleed, mortality data for AVB. Analysing the indicators, only 2 patients had rescue TIPSS, none had pre-emptive TIPSS. We had a 100% completion rate in abdominal imaging. Endoscopy was performed within 12 hours in 61.67% and within 24 hours in 91.67%. All patients with varices were appropriately managed (100%). Nonselective beta blockers were prescribed and surveillance arranged in 78.9% and 68% respectively (2022 national rate 55.6%). Antibiotics and terlipressin prescription rate were 57.17% Vs 46% nationally.Conclusions The audit shows acceptable guideline compliance in most areas. Re-bleeds were not operator-related (Hepatology/Luminal/Nutrition) suggesting case-mix/severity as unavoidable confounders. Endoscopy timing compliance was high; however secondary prevention and pre-endoscopic treatments remain suboptimal, mirroring 2022 UK audit findings. Importantly, our findings demonstrate a critical underutilisation of pre-emptive TIPSS (also reflected in the 2022 UK wide AUGIB audit), highlighting a significant gap between evidence-based guidance and real-world practice locally and nationally. These results prompt an urgent nation-wide need to reflect and improve awareness and implementation of pre-emptive TIPSS