Variceal Hemorrhage
Acute variceal hemorrhage is one of the most common reasons for intensive care unit admission of patients with cirrhosis, with mortality rates improved in recent years to 15–20 %. Patients with variceal bleeding require immediate and aggressive resuscitat
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Elizabeth A. Belloli and Steven E. Gay
Case Presentation A 33 year old man with history of alcoholic cirrhosis complicated by esophageal varices, recent alcoholic hepatitis, and gastroesophageal reflux disease presented to the Emergency Department with lightheadedness and melena. Initial vital signs showed a temperature of 36.6, BP 128/65, HR 113, RR 24, and SpO2 100 %. During evaluation in the Emergency Department, he developed large-volume hematemesis and hypotension. Labs initially demonstrated a hemoglobin of 7.0, platelets 255, INR 1.5, and total bilirubin 36. A nasogastric tube was inserted with return of more than 1 L of blood.
Electronic supplementary material The online version of this chapter (doi:10.1007/978-3-319-43341-7_62) contains supplementary material, which is available to authorized users. E.A. Belloli (*) Internal Medicine, Division of Pulmonary & Critical Care Medicine, University of Michigan Health System, Ann Arbor, MI, USA e-mail: [email protected] S.E. Gay Division of Pulmonary & Critical Care Medicine, University of Michigan Health System, Ann Arbor, MI, USA
Question How Should This Patient be Managed? Answer Patients with presumed variceal bleeding and increasing instability will require two primary steps in management: (1) Aggressive hemodynamic resuscitation with both volume and blood products, and (2) Hemostasis of the bleeding site which may include vasoconstrictor therapy and endoscopic intervention. In this patient, two large bore intravenous lines were placed and intravenous fluids and packed red blood cells were transfused. Pantoprazole and octreotide continuous infusions were initiated. The patient was emergently intubated and sedated prior to endoscopy. A massive resuscitation protocol was initiated. The patient’s condition worsened with hypovolemic shock leading to a 2-min episode of pulseless electrical activity which resolved with one dose of atropine, epinephrine and brief chest compressions. A SengstakenBlakemore tube was placed with inflation of the esophageal and gastric balloons. Erythromycin was administered as a bolus prior to endoscopy. Esophagogastroduodenoscopy (EGD) revealed massive edema and copious bright red blood in the oropharynx with large amounts of clotted blood in the entire esophagus. The scope could not be advanced past the distal esophagus due to abundant clot. No clear bleeding source was visualized, but variceal bleeding was assumed to be the etiology. The Sengstaken-Blakemore tube was replaced. Ceftriaxone was started for infection prophylaxis. Throughout this time, the patient
© Springer International Publishing Switzerland 2017 R.C. Hyzy (ed.), Evidence-Based Critical Care, DOI 10.1007/978-3-319-43341-7_62
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received nine units of packed red blood cells, five units of fresh frozen plasma, and 1 5-pack of platelets through a rapid infuser. The patient underwent emergent transjugular intrahepatic portosystemic shunt (TIPS) placement. His condition stabilized in the following day. Diuresis was performed in the subsequent da
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