A 52-year-old man with a 15-year history of alcohol use disorder presents to the emergency department with haematemesis and melaena. On examination, he is hypotensive (BP 85/50), tachycardic (HR 118/min), and has clinical signs of chronic liver disease including spider angiomata, palmar erythema, and ascites. Laboratory investigations reveal haemoglobin 7.2 g/dL, INR 2.8, albumin 2.1 g/dL, and total bilirubin 4.5 mg/dL. Upper gastrointestinal endoscopy confirms actively bleeding oesophageal varices. After initial resuscitation and blood product transfusion, what is the most appropriate next step in management?

Explanation

## Management of Acute Variceal Bleeding in Cirrhosis **Key Point:** Acute oesophageal variceal bleeding is a medical emergency requiring simultaneous pharmacological and endoscopic intervention. ### Stepwise Management Algorithm ```mermaid flowchart TD A[Acute variceal bleeding confirmed]:::outcome --> B[Resuscitation + IV access]:::action B --> C[Vasoactive agent: Octreotide/Terlipressin]:::action C --> D[Prophylactic antibiotics]:::action D --> E[Urgent endoscopy within 12 hrs]:::action E --> F{Endoscopic technique?}:::decision F -->|Preferred| G[Endoscopic Variceal Ligation]:::action F -->|Alternative| H[Endoscopic Sclerotherapy]:::action G --> I[Assess response]:::decision I -->|Controlled| J[Repeat EVL at 1-2 weeks]:::action I -->|Failure| K[TIPS consideration]:::urgent ``` ### Why Octreotide + EVL is Correct **High-Yield:** The combination of vasoactive agents (octreotide or terlipressin) PLUS endoscopic variceal ligation (EVL) is the gold standard for acute oesophageal variceal bleeding [cite:Harrison 21e Ch 297]. - **Octreotide mechanism:** Splanchnic vasoconstriction via somatostatin receptor agonism → reduces portal pressure gradient - **EVL mechanism:** Direct mechanical obliteration of varices → prevents rebleeding - **Combined approach:** 80–90% haemostasis rate; superior to either modality alone - **Timing:** Octreotide started immediately during resuscitation; endoscopy within 12 hours **Clinical Pearl:** In this patient, the presence of haemodynamic instability (BP 85/50), coagulopathy (INR 2.8), and low albumin (2.1 g/dL) indicates advanced cirrhosis (likely Child-Pugh C). Aggressive early intervention is essential to prevent mortality. ### Adjunctive Measures | Intervention | Rationale | Timing | | --- | --- | --- | | Prophylactic antibiotics (ceftriaxone) | Reduce bacterial translocation; SBP prophylaxis | Within 12 hrs of admission | | Fresh frozen plasma | Correct INR only if INR >1.5 AND active bleeding | As needed; not routine | | Packed RBC transfusion | Target Hb 7–9 g/dL (restrictive strategy) | Ongoing | **Warning:** Over-transfusion increases portal pressure and rebleeding risk — maintain restrictive transfusion strategy (target Hb 7–9 g/dL, not >10 g/dL). ### Rescue Therapies (if EVL fails) - **TIPS:** Reserved for refractory bleeding (failure of 2 EVL attempts) or variceal bleeding in portal vein thrombosis - **Balloon tamponade:** Temporary bridge only; high rebleeding rate (50%) and aspiration risk **Mnemonic — STOP BLEED:** **S**planchnic vasoconstriction (octreotide), **T**ransfuse restrictively, **O**ctreotide early, **P**rophylactic antibiotics, **B**lood products, **L**igation (EVL), **E**ndoscopy urgent, **E**valuate for TIPS if failure, **D**ischarge with beta-blockers.