A 52-year-old man with biopsy-proven cirrhosis (Child-Pugh Class B) presents with haematemesis. Upper endoscopy confirms bleeding oesophageal varices. After initial resuscitation and variceal ligation, he remains haemodynamically stable. What is the most appropriate next step in management?

Question

Accepted Answer

A. Administer ceftriaxone 1 g daily for 7 days and start propranolol 40 mg twice daily. ## Management of Acute Variceal Bleeding in Cirrhosis

### Clinical Context
This patient has:
- Confirmed variceal bleeding (haematemesis + endoscopic finding)
- Successful acute haemostasis (variceal ligation performed)
- Haemodynamic stability post-intervention
- Child-Pugh Class B cirrhosis (intermediate risk)

### Next Step: Antibiotic Prophylaxis + Beta-Blocker

**Key Point:** After successful endoscopic haemostasis in variceal bleeding, the two pillars of secondary prevention are:
1. **Antibiotic prophylaxis** — reduces bacterial translocation and rebleeding
2. **Beta-blocker therapy** — reduces portal pressure and prevents rebleeding

### Evidence-Based Approach

| Intervention | Timing | Rationale |
|---|---|---|
| **Ceftriaxone 1 g daily × 7 days** | Immediately after haemostasis | Reduces SBP incidence by ~50%, improves survival in variceal bleed |
| **Beta-blocker (propranolol/carvedilol)** | Start immediately | Reduces rebleeding risk from 42% → 25% over 12 months |
| **Repeat endoscopy** | 1–2 weeks (elective) | Complete variceal eradication; NOT urgent after successful ligation |
| **Octreotide** | During acute bleeding phase | Not needed once haemostasis achieved and patient stable |

**High-Yield:** Ceftriaxone (third-generation cephalosporin) is preferred over norfloxacin in cirrhosis because it achieves better tissue penetration and is effective against Gram-negative organisms causing spontaneous bacterial peritonitis (SBP).

### Why This Is Correct

Guideline consensus (AASLD, EASL) mandates:
- **Immediate antibiotic prophylaxis** after variceal bleeding to prevent bacterial translocation and rebleeding
- **Beta-blocker initiation** within 24 hours to reduce portal pressure
- **Elective repeat endoscopy** in 1–2 weeks for variceal eradication (not urgent if haemostasis achieved)

**Clinical Pearl:** The combination of antibiotics + beta-blockers reduces 6-week rebleeding from ~60% to ~30% and mortality by ~20%.

### Why Other Options Are Suboptimal

**Option 0 (Beta-blocker alone):** Omits antibiotic prophylaxis, which is now standard of care. Increases risk of SBP and rebleeding.

**Option 2 (Immediate repeat endoscopy + cyanoacrylate):** Repeat endoscopy is elective (1–2 weeks), not urgent. Variceal ligation has already achieved haemostasis; cyanoacrylate is reserved for gastric varices or when ligation fails.

**Option 3 (ICU + octreotide):** Octreotide is for acute bleeding control; patient is already stable post-ligation. ICU admission is not indicated in a haemodynamically stable patient after successful haemostasis.

Answer

B. Admit to ICU for continuous monitoring and start octreotide infusion

Answer

C. Perform repeat endoscopy immediately and inject cyanoacrylate

Answer

D. Start propranolol 40 mg twice daily and repeat endoscopy in 2 weeks

A 52-year-old man with biopsy-proven cirrhosis (Child-Pugh Class B) presents with haematemesis. Upper endoscopy confirms bleeding oesophageal varices. After initial resuscitation and variceal ligation, he remains haemodynamically stable. What is the most appropriate next step in management?

Explanation

Management of Acute Variceal Bleeding in Cirrhosis

Clinical Context

Next Step: Antibiotic Prophylaxis + Beta-Blocker

Evidence-Based Approach

Why This Is Correct

Why Other Options Are Suboptimal

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Intervention	Timing	Rationale
Ceftriaxone 1 g daily × 7 days	Immediately after haemostasis	Reduces SBP incidence by ~50%, improves survival in variceal bleed
Beta-blocker (propranolol/carvedilol)	Start immediately	Reduces rebleeding risk from 42% → 25% over 12 months
Repeat endoscopy	1–2 weeks (elective)	Complete variceal eradication; NOT urgent after successful ligation
Octreotide	During acute bleeding phase	Not needed once haemostasis achieved and patient stable