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A 54-year-old man with known alcohol-related cirrhosis is brought to the emergency department after two episodes of massive haematemesis at home. On arrival he is pale, diaphoretic and confused. Pulse 124/min, blood pressure 88/52 mmHg, respiratory rate 26/min, SpO2 92% on room air. Abdomen: firm splenomegaly, shifting dullness consistent with ascites, spider naevi on the chest. He has melaena on rectal examination. His initial haemoglobin is 68 g/L, platelets 62 x10^9/L, INR 1.9, bilirubin 48 micromol/L, albumin 28 g/L, urea 14 mmol/L, creatinine 96 micromol/L.
Questions
a) What is the diagnosis and what three bedside features point to the likely source of bleeding? (2 marks)
Diagnosis: acute variceal haemorrhage in a patient with decompensated alcohol-related cirrhosis and portal hypertension, presenting in hypovolaemic shock.
Three bedside pointers to a variceal source:
- Stigmata of chronic liver disease and portal hypertension — splenomegaly, ascites, spider naevi.
- Known cirrhosis with thrombocytopenia (62 x10^9/L from hypersplenism) and coagulopathy (INR 1.9).
- Massive haematemesis in a cirrhotic — assume variceal until endoscopy proves otherwise.
b) Outline your immediate resuscitation and pharmacotherapy in the first hour. (3 marks)
- Airway and breathing — protect the airway (he is confused and at risk of aspiration); give high-flow oxygen. Intubate early if haematemesis continues or airway is unsafe.
- Circulation — two large-bore (14G) cannulae, crossmatch 6 units; resuscitate with balanced crystalloid; insert urinary catheter.
- Restrictive transfusion — transfuse to a haemoglobin target of 70 to 80 g/L (over-transfusion raises portal pressure and worsens rebleeding — Villanueva 2013). He is at the target already; transfuse one unit to maintain perfusion given his shock, then hold.
- Vasoactive drug before endoscopy — terlipressin 2 mg IV bolus, then 1 mg every 4 hours (splanchnic vasoconstriction, lowers portal pressure).
- Prophylactic antibiotic — ceftriaxone 1 g IV once daily for 7 days — reduces infection, rebleeding and mortality.
- Vitamin K 10 mg IV; avoid routine FFP unless active bleeding with INR over 1.5 and coagulopathy-driven bleeding.
c) What definitive investigation and therapy should follow, and within what timeframe? (2 marks)
Upper GI endoscopy within 12 hours of admission, after resuscitation and vasoactive therapy are in place. It is both diagnostic and therapeutic. Findings will show oesophageal varices with stigmata of recent haemorrhage; first-line therapy is endoscopic band ligation (EBL). If these are gastric fundal varices, the therapy is cyanoacrylate (glue) injection.
d) This patient is high-risk. What intervention should be considered and within what timeframe, and what criteria define high-risk? (2 marks)
Pre-emptive (early) TIPS within 72 hours (ideally 24 hours). He meets high-risk criteria by Baveno VII: Child-Pugh C (7 to 13) OR Child-Pugh B with active bleeding at endoscopy. Pre-emptive TIPS reduces both rebleeding and mortality in these groups (Garcia-Pagan 2010 NEJM). His Child-Pugh is approximately 11 (bilirubin 2 points, albumin 2 points, INR 2 points, ascites 2 to 3 points, encephalopathy 1 to 2 points).
e) What is the prevention strategy once he survives this episode, and what is the goal of therapy? (1 mark)
Secondary prevention — because rebleed risk without prevention is 60 to 70 percent within 1 year. First-line is combination therapy: a non-selective beta-blocker (carvedilol 6.25 to 12.5 mg daily, or propranolol) plus serial endoscopic band ligation until variceal obliteration, then surveillance endoscopy every 3 to 6 months. The goal is to lower the hepatic venous pressure gradient (HVPG) to below 12 mmHg or by at least 20 percent (a haemodynamic response). In decompensated cirrhosis, refer early for liver transplantation (MELD-driven).