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Balloon tamponade
11%
2/19
Esophagogastroduodenoscopy
53%
10/19
Nadolol
16%
3/19
Packed red blood cells
Transjugular intrahepatic portosystemic shunt
5%
1/19
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This patient likely has acute variceal bleeding secondary to portal hypertension from cirrhosis (given his large volume of ascites seen on ultrasound). This patient is no longer actively vomiting and is currently stable and should have esophagogastroduodenoscopy (EGD) to visualize any potential bleeding and stop the bleeding if indicated. Cirrhosis can occur secondary to hepatitis infections and most commonly alcohol abuse. The increased resistance of the liver can cause esophageal varices to form which can bleed. Any patient with variceal bleeding should initially be managed with IV fluids, repletion of coagulation factors if needed, antiemetics, proton pump inhibitors, ceftriaxone, and EGD. EGD can provide sclerotherapy or banding as treatment options if bleeding varices are visualized. Figure A is an ultrasound demonstrating a large volume of abdominal ascites suggesting a diagnosis of cirrhosis. Incorrect Answers: Answer 1: Balloon tamponade refers to the use of balloons to stop bleeding from the esophagus or stomach. It is not generally a treatment of choice for stable patients with bleeding esophageal varices because of a high rate of rebleeding and esophageal injury. It may be appropriate with persistent bleeding that is rapid and unable to be controlled by other means. Answer 3: Nadolol is a beta-blocker which decreases liver blood flow without interfering with liver function. It can be used to manage portal hypertension but is not indicated in the treatment of acute variceal bleeds. It would be indicated as prophylaxis against future bleeds. Answer 4: Packed red blood cells are indicated for patients rapidly bleeding or for patients with a hemoglobin < 7.0 g/dL. Answer 5: Transjugular intrahepatic portosystemic shunt (TIPS) may be indicated as long-term therapy for this patient’s portal hypertension. It could reduce the incidence of rebleeding but increases the risk of hepatic encephalopathy since the liver is now bypassed. Bullet Summary: Patients with variceal bleeding must undergo EGD to localize and stop the bleeding.
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