A 58-year-old man with a 10-year history of cirrhosis (Child-Pugh B) presents to the emergency department with haematemesis and melaena. On examination, he is haemodynamically unstable (BP 90/60 mmHg, HR 110/min). After two large-bore IV lines are secured and initial fluid resuscitation begun, what is the most appropriate next step in management?

Explanation

## Clinical Context This patient has signs of variceal bleeding (cirrhosis, haemodynamic instability, haematemesis + melaena). The key management principle in suspected variceal bleeding is **haemodynamic stabilisation + pharmacological therapy + endoscopy**, not investigation-first or endoscopy-first in isolation. ## Rationale for Correct Answer **Key Point:** In haemodynamically unstable variceal bleeding, empirical variceal therapy (vasoconstrictor + antibiotics) should be initiated **before or concurrent with endoscopy**, not after imaging or after correction of coagulopathy alone. **High-Yield:** Terlipressin (or octreotide) reduces portal pressure and controls variceal bleeding in ~50% of cases within minutes. Ceftriaxone (or norfloxacin) reduces bacterial translocation and 7-day mortality in cirrhotic patients with GI bleeding. Both are given empirically while endoscopy is being arranged. **Clinical Pearl:** The sequence is: 1. Secure IV access, resuscitate (target MAP >65 mmHg) 2. **Start vasoconstrictor + antibiotics immediately** (do not wait for endoscopy) 3. Correct coagulopathy if INR >1.5 (FFP or PCC) 4. Urgent endoscopy within 12 hours ## Why Endoscopy Timing Matters Endoscopy is diagnostic AND therapeutic (variceal ligation/sclerotherapy), but it should not delay pharmacological therapy. Haemodynamically unstable patients benefit from vasoconstrictor-induced reduction in portal pressure **before the endoscopist arrives**. ## Guideline Reference [cite:Harrison 21e Ch 298] and [cite:AASLD/ASGE Variceal Bleeding Guidelines] recommend empirical variceal therapy in suspected variceal bleeding before or concurrent with endoscopy.