Esophageal Varices and Hematmemasis

[admin]

STEM:
You are the general surgical SHO on call in a district general hospital with no gastroenterology service and have been asked to attend A&E to review a patient who had profuse haematemesis and was becoming haemodynamically unstable.

The patient is known to consume excessive amounts of alcohol and make use of other substances. On arrival in A&E, you find a patient with a BP of 100/70, HR 120, RR 30, Temperature 37.4°C and SpO₂ of 91%.

What are your differentials?

Spoiler

Bleeding oesophageal varices due to portal HTN caused by cirrhotic liver
Mallory–Weiss tear
Boerhaave's syndrome
Bleeding peptic ulcer

What are your concerns regarding this patient?

Spoiler

Ongoing bleeding resulting in hypovolaemia, as the patient has cirrhosis and clotting abnormalities.
Likelihood of complications such as:
Hepatic encephalopathy
AKI
Hepatorenal syndrome

How will you manage this patient?

Spoiler

I will treat the patient according to CCrISP protocol and admit this patient to HDU.
Active resuscitation, reduction of portal venous pressure and measures to avoid hepatic encephalopathy:
High flow oxygen
Venous access
Immediate cross-matching, 2–4 units of blood after discussing with haematologists
Fresh blood transfusion, FFP, platelets after consultation with haematologist
Close monitoring (pulse, blood pressure, hourly urine output, central venous pressure)
Assessment of coagulation status
Prothrombin time
Platelet count

Control of bleeding

Spoiler

Tamponade (Minnesota tube) if bleeding uncontrolled
Pharmacological measures (e.g. vasopressin / octreotide)
Urgent endoscopy. Banding or injection sclerotherapy