A 52-year-old man with alcoholic cirrhosis (Child-Pugh Class C) presents with haematemesis and melaena. On examination, he is haemodynamically unstable (BP 90/60 mmHg, HR 110/min). Upper GI endoscopy confirms oesophageal variceal bleeding. After initial resuscitation with 2 units of packed RBCs and fresh frozen plasma, what is the most appropriate next step in management?

Explanation

## Management of Acute Variceal Bleeding in Cirrhosis ### Immediate Management Priorities **Key Point:** Acute variceal bleeding in decompensated cirrhosis requires simultaneous pharmacological AND endoscopic therapy within the first 12 hours. ### The Correct Approach: Octreotide + Variceal Band Ligation 1. **Pharmacological control** — Octreotide (bolus 50 μg IV, then 50 μg/hr infusion) reduces portal pressure and controls bleeding in ~80% of cases [cite:Harrison 21e Ch 297] 2. **Definitive haemostasis** — Endoscopic variceal ligation (EVL) is superior to sclerotherapy (lower rebleeding rates, lower mortality, fewer complications) 3. **Antibiotic prophylaxis** — Ceftriaxone or norfloxacin should be started concurrently to prevent bacterial infections (SBP, UTI) which occur in ~40% of variceal bleeders ### Why This Sequence Works ```mermaid flowchart TD A[Variceal bleeding confirmed]:::outcome --> B[Resuscitate + Octreotide infusion]:::action B --> C{Haemodynamically stable?}:::decision C -->|Yes| D[Urgent endoscopy for EVL]:::action C -->|No| E[Transfuse to target Hb 7-9 g/dL]:::action E --> D D --> F[Add antibiotic prophylaxis]:::action F --> G[Monitor for rebleeding]:::outcome ``` **High-Yield:** EVL is now the endoscopic therapy of choice over sclerotherapy because it has: - Lower rebleeding rates (20% vs 40%) - Lower mortality (6-month: 16% vs 29%) - Fewer complications (strictures, perforation) ### Timing **Clinical Pearl:** Endoscopy should be performed within 12 hours of admission in haemodynamically stable patients and immediately (after brief resuscitation) in unstable patients. This patient is unstable but has been resuscitated; EVL should proceed urgently. ### Antibiotic Prophylaxis **Key Point:** All variceal bleeders receive prophylactic antibiotics for 7 days: - **First choice:** Ceftriaxone 1 g IV daily (covers Gram-negative organisms) - **Alternative:** Norfloxacin 400 mg BD (if no IV access) - Reduces bacterial infections from 40% → 10–15% - Improves survival in advanced cirrhosis [cite:Harrison 21e Ch 297]