Esophageal Varices Bleed

Pt with h/o liver cirrhosis, portal hypertension, varices presents with acute onset hematemesis. Varices diagnosis previously established during q3 year screening endoscopy. Active hematemesis with bright red-blood, gynecomastia, hepatomegaly, caput medusa on exam.

  • Obtain CBC, CMP, PT, PTT, INR, FOBT

  • Surgery consult for urgent EGD; may require banding

  • Start octreotide 50mcg IV bolus followed by 25mcg/hour IV x2 days

  • Bactrim SS BID x 7 days

  • H/o previous variceal bleeds; consider TIPS procedure s/p stabilization

  • Discharge with prophylactic propranolol 40mg BID

  • Propranolol contraindicated; start isosorbide mononitrate 20mg BID

  • Yearly EGD due to established variceal diagnosis

  • Pt counseled about significantly elevated risk for re-bleed during 6 weeks following discharge

  • Pt advised that long-term therapy may involve liver transplant

Notes

  • Rate of variceal bleeding in patients with established diagnosis is 10-30% per year

  • For patient's with Bactrim allergy, use Norfloxacin