Variceal Hemorrhage, Acute

Vomiting Blood

Step 1: View clinicals

A 55-year-old man with end-stage cirrhosis secondary to alcohol abuse presents around 30 minutes after vomiting a large amount of bright red blood. This is his first such episode. An endoscopy around a year ago revealed multiple grade IV esophageal varices, which were ligated at that time. He has also been on oral propranolol therapy since then. His medical and surgical histories are otherwise unremarkable. He has continued to consume half a bottle of whiskey a day, against medical advice.


Step 2: Order all relevant investigations

Complete blood count

WBC/DC: 12,000/mm3 (5,000 - 11, 000) Hb: 10.2 g/dL (12 - 16) PCV (Hct): 30% (40 - 52) Plt: 89,000/mm3 (150,000 - 400,000)

Coagulation profile

INR: 1.9 (0.9-1.1) APTT: 40 sec (normal) TT: 15 sec (normal)

Ultrasound abdomen

The ultrasound is suggestive of liver parenchymal disease. A moderate amount of free fluid is present.

Liver function tests

AST: 250 IU/L (9-51) ALT: 135 IU/L (13-40) ALP: 319 IU/L (34-122) Total bilirubin: 3.2 mg/dL (0.1-1.1) Albumin: 2.4 g/dL (3.5-5.5)


Step 3: Select appropriate management

Urgent Endoscopy
Antibiotics
Octreotide
Transfuse packed red cells


Score: ★★☆