Gastrointestinal · Year 2 · from Gastrointestinal
Case 2: Variceal Bleeding in Cirrhosis
Patient Presentation
Demographics: 55-year-old male
Chief Complaint: Massive vomiting of blood for 2 hours
History of Present Illness: The patient experienced sudden onset of vomiting large amounts of bright red blood (estimated > 1 liter). He has a known history of alcoholic cirrhosis and was previously told he has "enlarged veins in his esophagus." He stopped taking his propranolol 2 weeks ago because he felt dizzy. He continues to drink alcohol daily.
Past Medical History: Alcoholic cirrhosis (Child-Pugh Class B), known esophageal varices (large, never bled), prior ascites requiring paracentesis, hepatic encephalopathy
Social History: Active alcoholism (1 pint of vodka daily), no IV drug use
Physical Examination
- Vital Signs: BP 78/48 mmHg, HR 128 bpm, RR 24/min, Temp 37.8C
- General: Pale, confused male with active hematemesis, blood on gown and bed
- HEENT: Icteric sclerae, blood in oropharynx
- Abdomen: Distended with shifting dullness (ascites), caput medusae, splenomegaly
- Extremities: Palmar erythema, spider angiomata, muscle wasting
- Neurologic: Disoriented; asterixis present
Workup and Results
- CBC: Hemoglobin 6.8 g/dL, Platelets 62,000, WBC 11,200
- Coagulation: INR 2.1, PTT 38 seconds
- BMP: Sodium 128 mEq/L, Creatinine 1.8 mg/dL (baseline 1.0)
- LFTs: Total bilirubin 4.2 mg/dL, Albumin 2.4 g/dL, AST 85 U/L, ALT 52 U/L
- Child-Pugh Score: 10 (Class C: bilirubin > 3, albumin < 2.8, INR > 2.3, ascites, encephalopathy)
- MELD Score: 24
- EGD (within 12 hours): Large esophageal varices (Grade III) with active spurting from one varix; red wale signs on remaining varices
Endoscopic image demonstrating esophageal varices. Large variceal columns are visible with red wale signs (red streaks on the varix surface), indicating high risk for bleeding. Endoscopic band ligation is the first-line treatment.
Image Source: Wikimedia Commons. Jmarchn, CC BY-SA 3.0
Diagnosis
Acute Variceal Hemorrhage in Decompensated Cirrhosis (Child-Pugh C)
Clinical Correlation
Variceal bleeding is a life-threatening complication of portal hypertension, carrying 15-20% mortality per bleeding episode. This case highlights several critical concepts:
Unique Physiology of Variceal Bleeding:
- Portal hypertension causes collateral formation at sites of portosystemic anastomoses
- Esophageal varices develop when hepatic venous pressure gradient (HVPG) exceeds 10-12 mmHg
- Bleeding risk correlates with varix size, red wale signs, and severity of liver disease
- Approximately 30% of patients with large varices will bleed within 2 years
Critical Differences from Non-Variceal Bleeding:
- Restrictive transfusion (Hgb 7-8 g/dL) is even more important - overtransfusion increases portal pressure and worsens bleeding
- Coagulopathy in cirrhosis is complex - both pro- and anti-coagulant factors are depleted; INR does not reliably indicate bleeding risk; routine FFP is not indicated
- Prophylactic antibiotics reduce mortality - infection is common and worsens outcomes
Why He Bled:
- Discontinued propranolol (removes portal pressure-lowering effect)
- Ongoing alcohol use (continued liver injury)
- Large varices with red wale signs (high-risk stigmata)
- Child-Pugh C status (most severe liver disease)
Treatment
Immediate Resuscitation:
- Airway protection: Endotracheal intubation (altered mental status + active hematemesis = high aspiration risk)
- Two large-bore IV access
- Conservative fluid resuscitation - avoid over-resuscitation
- Blood transfusion targeting Hgb 7-8 g/dL
Pharmacotherapy (initiated immediately, before endoscopy):
- Octreotide: 50 mcg IV bolus, then 50 mcg/hour continuous infusion for 3-5 days (reduces splanchnic blood flow and portal pressure)
- Ceftriaxone 1 g IV daily for 7 days - prophylactic antibiotics reduce infections, rebleeding, and mortality
- Avoid nephrotoxic agents - patient at high risk for hepatorenal syndrome
Endoscopic Therapy (within 12 hours):
- Endoscopic band ligation (EBL) - first-line for esophageal varices
- Band placed directly on actively bleeding varix, then on remaining large varices
- Superior to sclerotherapy with fewer complications
Rescue Therapies (if endoscopy fails):
- Balloon tamponade (Sengstaken-Blakemore or Minnesota tube) - temporary bridge, not definitive therapy; high complication rate
- TIPS (Transjugular Intrahepatic Portosystemic Shunt) - creates portosystemic shunt to decompress portal system
Early TIPS Consideration: This patient is Child-Pugh C with score 10 - meets criteria for early or "preemptive" TIPS within 72 hours (ideally 24 hours). Studies show early TIPS in high-risk patients (Child-Pugh C 10-13, or Child-Pugh B with active bleeding) improves survival.
Secondary Prophylaxis (after acute episode resolves):
- Resume non-selective beta-blocker (propranolol, nadolol, or carvedilol)
- Serial band ligation every 2-4 weeks until varix eradication
- Combination of beta-blocker + band ligation provides best protection
- Alcohol cessation counseling and liver transplant evaluation