Your patient is VOMITING BLOOD! Right in front of you.
High Yield Review - Esophageal Variceal Hemorrhage
Case: A 52 y/o male who was just admitted to medical floor for new onset abdominal ascites and in acute alcohol withdrawal. You get called by the patients nurse explaining that the patient had bloody emesis, and is now tachycardic and hypotensive a rapid response is called. You go see the patient and the
nurse shows you this.
The patient is alert but is increasingly somnolent and slow
to respond to questions. The SBP is 70 mmhg palp. He proceeds to have large volume bloody emesis and becomes obtunded.
You successfully intubate the patient for hemodynamic instability and airway protection in the setting of hemmorhagic shock
You request for the placement of 2 large bore 18g peripheral IVs
Stat Blood Blood request for O Rh -. The patient is sent to
the ICU.
Arterial line and Central venous catheter line was placed for further additional access for multiple drips ( vasopressors, analegesia and sedation) and IV infusions ( normal saline and IV antibiotics )
Additional Stat labs were sent, abdominal paracentesis was performed and periotneal fluid analysis was sent to the lab and
results are pending..
In the mean time He was started on pantoprazole drip , octreotide drip, and ceftriaxone.
GI was consulted for urgent endoscopy which was performed and showed
Large Esophageal Varices
Banding ( Black Arrows )
EGD Procedure WATCH!
Case Cont. Possible Outcomes
1. No Further bleeding
- No further bleeding was noted, he was extubated and hemodynamically stable, and the patient was
transferred out of the ICU.
- He was started on a Beta blocker
-Will need a follow up in the GI clinic for a repeat EGD with band ligation in 1-2 weeks
2. Continued Bleeding
- Continued bleeding was noted NOT alleviated by Band Ligation/Sclerotherapy
- TEMPORARY placement of Balloon Tamponade needed
3. Re-bleeding
- Will need to repeat EGD and Banding / Sclerotherapy
4. Recurrent Hemorrhage or Continued Bleeding
- He will need TIPS or Shunt surgery
Case Clues - Esophageal Variceal Hemorrhage
- Variceal Hemorrhage + Abdominal Ascites ( Start thinking risk for SBP)
- Alcohol history ( suspect sequelae of liver cirrhosis, Portal Hypertension, and hemmorhhage due to varices)
- The blood is fresh in appearance ( This favors Variceal bleed, Mallory weiss tears) if blood was coffee ground think PUD
- Pantoprazole drip ( Add this because you don't know if there is PUD until EGD performed )
- Octreotdie drip ( Decreases portal pressure )
- EGD for Band ligation or sclerotherapy ( See the Procedure )
Know it for the boards - Esophageal Variceal Hemorrhage!
- Start Octreotide drip ( reduces portal pressure )
- Spontaneous Bacterial Peritonitis is a high risk infection in active variceal hemmorhage so start IV Antibiotics ( e.g. Ceftiaxone )
- Urgent EGD for band ligation or scleotherapy
- Know what esophageal varices look like on EGD
So what If ?
If 1. No re-bleeding: Start a non selective beta blocker,
(nadolol, propranolol ) and repeat EGD w banding in 1-2 weeks
If 2. Continued Bleeding: Place Balloon Tamponade
( Temporary ) then TIPS/Shunt
If 3. Early Re-bleeding: Repeat EGD banding/sclerotherapy
If 4. Recurrent Hemorrhaging: Then TIPS/Shunt
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