On this page
Study tools
Write your answer
Saved on this device. No marking — you are the marker.
Q1: Pathophysiology (2 min)
"Why do varices form and why do they bleed?"
- Cirrhosis distorts hepatic architecture + activates contractile hepatic stellate cells -> increased intrahepatic vascular resistance.
- Splanchnic vasodilatation (NO, glucagon) increases portal inflow -> portal hypertension.
- HVPG over 5 mmHg = portal hypertension; over 10 = clinically significant (varices begin); over 12 = bleeding threshold.
- Blood is shunted through embryonic portosystemic collaterals at the gastro-oesophageal junction -> submucosal veins dilate into varices.
- Varices bleed by Laplace's law: wall tension T = (P x r) / w; as varix enlarges (r) and wall thins (w), wall stress exceeds tensile strength -> rupture above HVPG 12 mmHg.
Q2: Assessment and investigations (2 min)
"How do you assess a suspected variceal bleed?"
- ABCDE: airway protection (intubate if encephalopathic/massive haematemesis), oxygen, two large-bore IVs, restrictive transfusion (Hb 70 to 80).
- Look for stigmata of chronic liver disease and portal hypertension (splenomegaly, ascites, caput).
- Labs: FBC, U&E, LFT, INR, lactate, blood group and crossmatch 4 to 6 units; calculate Child-Pugh and MELD.
- Upper GI endoscopy within 12 hours — diagnostic and therapeutic; assess varix site (oesophageal vs gastric), size, stigmata (active spurting, white nipple, red wale).
- HVPG measurement at specialist centres; the over 12 mmHg threshold governs bleeding risk.
Q3: Acute management (3 min)
"Walk me through the acute management bundle."
- RATE: Resuscitate (restrictive Hb 70 to 80, airway first); Antibiotics plus vasoActive drug (ceftriaxone 1 g IV OD + terlipressin 2 mg IV bolus then 1 mg q4h) — both BEFORE endoscopy; Tie (band ligation within 12 h; cyanoacrylate for gastric; balloon tamponade or covered stent as a 24-h bridge); Early TIPS within 72 h for high-risk.
- Two mortality-reducing interventions: prophylactic ceftriaxone and restrictive transfusion (Villanueva 2013).
- Endoscopic band ligation controls 80 to 90 percent of oesophageal variceal bleeds; cyanoacrylate glue for gastric fundal varices.
- Rescue TIPS for failure despite drugs plus endoscopy; pre-emptive TIPS within 72 h for Child-Pugh C 7 to 13 or Child-Pugh B with active bleeding (Garcia-Pagan 2010).
Q4: Prevention (2 min)
"How do you prevent the next bleed?"
- Primary prevention (varices, never bled): non-selective beta-blocker (carvedilol 6.25 to 12.5 mg daily preferred; or propranolol/nadolol) OR endoscopic band ligation, for medium/large varices or small varices with red signs / Child-Pugh B-C.
- Secondary prevention (survived a bleed): NSBB plus serial band ligation — lowest rebleed rate.
- Goal: HVPG reduced to below 12 mmHg or by at least 20 percent (haemodynamic response).
- TIPS for rebleeding despite combination therapy; liver transplantation for decompensated cirrhosis (MELD-driven).
- Carvedilol lowers portal pressure more than propranolol (alpha-1 blockade) — modern NSBB of choice.