Sun28November0628PM 15

A 42-year-old alcoholic is admitted by emergency ambulance after vomiting approximately 250 ml of fresh blood.

He is known to have oesophageal varices and failed to attend an appointment for prophylactic banding some three months earlier. He is poorly compliant with other therapies including propranolol and spironolactone.

On examination his BP is 105/70 mmHg, pulse is 95 and regular. There is tenderness in the epigastrium.

Investigations show:

Hb 84 g/L (130-180)

WCC 10.5 ×109/L (4-10)

PLT 95 ×109/L (130-400)

Na 137 mmol/L (135-145)

K 4.9 mmol/L (3.5-5.5)

Cr 128 µmol/L (70-120)

Urea 14.1 mmol/L (2.5-8)

INR 1.2 -

There is an infusion of normal saline running.

Which of the following is the most important next step?

(Please select 1 option)

IV antibiotics

IV omeprazole

Injection sclerotherapy

IV terlipressin Correct

TIPS

Explanation

In this situation IV terlipressin is proven to impact positively on mortality in acute variceal bleeding. It reduces mortality by 34% versus placebo. It has also been shown to reduce failure of haemostasis by 25% in patients who undergo variceal banding. Although mortality is low in banded patients and therefore numbers in studies are small, significance for benefit of terlipressin vs. sclerotherapy alone was nearly achieved. For these reasons NICE recommend it is started as soon as possible after presentation with variceal haemorrhage.

Injection sclerotherapy is recommended for gastric varices. In oesophageal variceal bleeding, banding is associated with a better outcome. Prophylactic antibiotics should be started, but in this situation IV terlipressin is more pressing.

There is no evidence for using IV PPI for variceal haemorrhage, and TIPS is reserved for patients where haemostasis is not achieved despite banding.

Reference:

Ioannou GN, Doust J, Rockey DC. Systematic review: terlipressin in acute oesophageal variceal haemorrhage. Aliment Pharmacol Ther. 2003;17:53-64.

NICE. Acute upper gastrointestinal bleeding in over 16s: management (CG141).

Answer Statistics

1

10%

2

7%

3

5%

4

78%

5

2%

Times answered: 291