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A 67-year-old man with known alcoholic cirrhosis presents with large-volume haematemesis and melaena. Heart rate is 118/min, blood pressure 88/54 mmHg, SpO2 96% on air. He is slightly confused. Haemoglobin is 7.2 g/dL, platelets 78 × 10⁹/L, INR 1.7. He takes no anticoagulants. There is ascites and spider naevi.
Questions
a) What is the most likely bleeding source and which risk scores would you calculate at the front door? (2 marks)
- Most likely oesophageal (or gastric) variceal haemorrhage in decompensated cirrhosis (1).
- Glasgow-Blatchford Score for pre-endoscopy severity/disposition; clinical Rockall may be used; Child-Pugh/MELD for liver severity/prognosis (1).
b) Detail the resuscitation and specific medical therapy before endoscopy (drugs with doses). (4 marks)
- ABC: protect airway if encephalopathy/ongoing massive haematemesis; two large-bore cannulae; monitor (1).
- Cautious fluids + restrictive transfusion target Hb ~7–8 g/dL (avoid over-transfusion) (1).
- Terlipressin 2 mg IV every 4 hours (or octreotide 50 mcg bolus then 50 mcg/h if terlipressin unavailable) (1).
- Prophylactic antibiotic e.g. ceftriaxone 1 g IV daily (0.5).
- Correct coagulopathy thoughtfully; NPO; urgent endoscopy pathway within 12 hours (0.5).
c) What endoscopic therapy is first-line for oesophageal varices, and what if it fails? (2 marks)
- Endoscopic variceal band ligation first-line for oesophageal varices (1).
- Rescue: balloon tamponade or self-expanding metal stent as bridge → salvage TIPS for refractory bleeding (1).
d) Name two differences in the ulcer-bleed pathway versus variceal pathway. (2 marks)
Any two (1 each): ulcer pathway uses high-dose PPI after endoscopic haemostasis (Forrest-guided therapy); no routine terlipressin/antibiotics unless cirrhosis; H. pylori testing/treatment; endoscopic dual therapy for high-risk Forrest lesions rather than banding.