Portal Hypertension — Variceal Bleeding Management

A 58-year-old male with cirrhosis and portal hypertension presents with hematemesis. Upper endoscopy confirms bleeding esophageal varices. After initial resuscitation and variceal ligation, the patient develops refractory variceal bleeding despite two sessions of endoscopic therapy. Which of the following is the most appropriate next step in management?

A 48-year-old woman with Child-Pugh Class C cirrhosis secondary to hepatitis B presents with a first episode of haematemesis. Endoscopy reveals bleeding oesophageal varices. After successful haemostasis with endoscopic variceal ligation (EVL), she is stabilised. What is the most appropriate long-term management strategy to prevent variceal rebleeding?

A 42-year-old man with a 10-year history of alcohol-related cirrhosis presents to the emergency department with haematemesis and melaena. On examination, he is haemodynamically unstable (BP 85/55, HR 118/min), with clinical signs of portal hypertension. Urgent upper endoscopy confirms actively bleeding oesophageal varices. After two units of packed RBCs and fresh frozen plasma, bleeding persists. What is the most appropriate next step in management?

A 38-year-old woman with alcoholic cirrhosis (Child-Pugh Class C) presents with her second episode of variceal bleeding within 6 weeks. She underwent successful endoscopic variceal ligation (EVL) for the first bleed and was discharged on propranolol. On this admission, upper endoscopy shows active bleeding from esophageal varices. After 2 attempts at EVL fail to achieve hemostasis, blood pressure drops to 85/50 mmHg despite aggressive transfusion. What is the most appropriate next intervention?

A 42-year-old man with known cirrhosis (Child-Pugh Class B) presents to the emergency department with hematemesis and melena. On examination, blood pressure is 95/60 mmHg, heart rate 118/min, and he has clinical signs of portal hypertension. Upper endoscopy confirms actively bleeding esophageal varices. After initial resuscitation with 2 units of packed RBCs and fresh frozen plasma, what is the most appropriate next step in management?