Internal Medicine · Year 3 · from Internal Medicine

Case 3: Variceal Hemorrhage

Patient Presentation

A 55-year-old man with known alcohol-related cirrhosis (Child-Pugh B) presents with massive hematemesis. He has vomited approximately 500 mL of blood en route to the hospital. He was not compliant with his variceal surveillance and has not seen a gastroenterologist in 2 years. He reports continued alcohol use.

Vital Signs

  • Blood Pressure: 82/48 mmHg
  • Heart Rate: 128 bpm
  • Respiratory Rate: 26/min
  • Oxygen Saturation: 92% on room air
  • Temperature: 36.5°C

Physical Examination

  • General: Somnolent, icteric
  • HEENT: Blood in oropharynx
  • Cardiovascular: Tachycardic, weak pulses
  • Abdomen: Distended with ascites, caput medusae, splenomegaly
  • Extremities: 2+ edema, spider angiomata
  • Neurologic: Lethargic, asterixis present

Laboratory Results

  • Hemoglobin: 6.8 g/dL
  • Platelets: 68,000/μL
  • INR: 1.9
  • Bilirubin: 4.2 mg/dL
  • Albumin: 2.4 g/dL
  • Creatinine: 1.8 mg/dL (baseline 1.0)

Clinical Image

Figure 3: Endoscopic image of large esophageal varices with red wale signs (longitudinal red streaks), indicating high risk of bleeding.

Image Source: Educational illustration for teaching purposes.

Questions

  1. What pharmacologic therapy should be initiated immediately for suspected variceal bleeding?
  • A) Proton pump inhibitor only
  • B) Octreotide (or terlipressin) plus antibiotics (ceftriaxone)
  • C) Vasopressin
  • D) Beta-blocker
  1. What is the target hemoglobin for transfusion in variceal bleeding?
  • A) >10 g/dL
  • B) 7-8 g/dL (restrictive transfusion)
  • C) >12 g/dL
  • D) >9 g/dL
  1. When should endoscopy be performed in suspected variceal bleeding?
  • A) After 24 hours of stabilization
  • B) Within 12 hours of presentation
  • C) Only if octreotide fails
  • D) After correcting coagulopathy completely
  1. Why are prophylactic antibiotics important in variceal bleeding?
  1. What rescue therapy is available if endoscopic treatment fails?

Answers

  1. B) Octreotide (or terlipressin) plus antibiotics (ceftriaxone) - Vasoactive drugs (octreotide 50 mcg bolus then 50 mcg/hour) reduce splanchnic blood flow and portal pressure. Prophylactic antibiotics (ceftriaxone 1g IV daily) reduce bacterial translocation, SBP risk, and mortality.
  1. B) 7-8 g/dL (restrictive transfusion) - Restrictive transfusion (target Hgb 7-8 g/dL) is associated with better outcomes in variceal bleeding than liberal transfusion. Over-transfusion can increase portal pressure and re-bleeding risk.
  1. B) Within 12 hours of presentation - Early endoscopy (within 12 hours) allows diagnosis and treatment with band ligation (preferred) or sclerotherapy. Intubation for airway protection may be needed before endoscopy in patients with altered consciousness.
  1. Importance of prophylactic antibiotics:
  • Cirrhotic patients have impaired immune function and gut barrier
  • Bleeding promotes bacterial translocation
  • Antibiotics reduce infections (SBP, pneumonia, UTI) from 45% to 14%
  • Reduce mortality and re-bleeding
  • Ceftriaxone 1g IV daily for 7 days (or norfloxacin if no IV access)
  1. Rescue therapy for refractory variceal bleeding:
  • Balloon tamponade: Sengstaken-Blakemore or Minnesota tube (temporizing measure, max 24 hours)
  • TIPS (Transjugular Intrahepatic Portosystemic Shunt): Creates portosystemic shunt to decompress varices
  • Self-expanding esophageal stent: Alternative to balloon tamponade
  • Surgery: Rarely needed; portocaval shunt or devascularization
  • Early TIPS (within 72 hours) improves outcomes in high-risk patients

Learning Points

  1. Risk stratification using Glasgow-Blatchford Score (UGIB) guides management intensity and timing of endoscopy.
  1. Resuscitation with IV fluids and blood transfusion (target Hgb 7-8 g/dL) precedes definitive diagnosis in hemodynamically unstable patients.
  1. Upper GI bleeding typically presents with hematemesis or melena, elevated BUN/Cr ratio; lower GI bleeding presents with hematochezia and normal BUN.
  1. Variceal bleeding requires vasoactive drugs (octreotide), antibiotics, restrictive transfusion, and urgent endoscopy with band ligation.
  1. Anticoagulation management in GI bleeding requires balancing bleeding risk against thromboembolic risk; reversal agents are available for life-threatening hemorrhage.

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