Topic:Malabsorption syndromes, acid peptic diseases, Viral hepatitis and cirrhosis of liver.
Question: 42 year old, male, known case of alcoholic liver disease, which portal hypertension is brought to casualty with severe hematemesis. Describe the management in this case.
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Initial Resuscitation:
- Hemodynamic Stabilization:
- Establish two large-bore intravenous (IV) lines with normal saline or Ringer’s lactate.
- Administer oxygen via nasal cannula or face mask to maintain SpO2 > 94%.
- Monitor vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation.
- Blood Transfusion:
- Transfuse packed red blood cells (PRBCs) to maintain hemoglobin levels > 7 g/dL.
- Consider transfusing fresh frozen plasma (FFP) if the patient has coagulopathy (INR > 1.5).
- Monitor for signs of transfusion-related complications, such as transfusion-associated circulatory overload (TACO).
- Vasopressors:
- Administer vasopressors, such as norepinephrine or vasopressin, to maintain mean arterial pressure (MAP) > 65 mmHg.
- Titrate the vasopressors to the desired hemodynamic response while avoiding excessive tachycardia or hypertension.
- Endoscopy:
- Perform urgent upper endoscopy to identify the source of bleeding and for potential therapeutic intervention.
- Endoscopic therapies may include:
- Sclerotherapy: Injection of a sclerosing agent, such as polidocanol or ethanolamine oleate, into the bleeding vessel to promote thrombosis and stop the bleeding.
- Band ligation: Placement of rubber bands around the bleeding vessel to occlude it and stop the bleeding.
- Hemoclip placement: Application of metal clips to the bleeding vessel to compress it and stop the bleeding.
- Pharmacological Therapy:
- Administer intravenous proton pump inhibitors (PPIs), such as omeprazole or pantoprazole, to reduce gastric acid secretion and prevent further bleeding.
- Consider administering octreotide, a somatostatin analog, to inhibit splanchnic blood flow and reduce portal hypertension.
- Balloon Tamponade:
- If endoscopic therapy is unsuccessful or not feasible, consider placing a Sengstaken-Blakemore tube or Minnesota tube for balloon tamponade of the bleeding esophageal varices.
- Inflate the balloons under endoscopic guidance to compress the varices and stop the bleeding.
- Transjugular Intrahepatic Portosystemic Shunt (TIPS):
- In patients with refractory variceal bleeding, consider performing TIPS to create an alternative pathway for blood flow from the portal vein to the hepatic vein, bypassing the cirrhotic liver.
- TIPS can be performed percutaneously or surgically.
Monitoring and Follow-Up:
- Monitor the patient closely for signs of recurrent bleeding, such as hematemesis, melena, or hypotension.
- Repeat endoscopy as needed to assess the effectiveness of therapy and to identify any new bleeding sources.
- Monitor liver function tests and coagulation parameters regularly.
- Provide nutritional support to prevent malnutrition and promote healing.
- Consider long-term management strategies for alcoholic liver disease, including alcohol cessation, liver transplantation, and management of complications such as ascites and hepatic encephalopathy.
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