Case 26: Variceal Bleeding
Wednesday, September 7th, 2011Author: Dr Ian Stell
No prizes for recognising these impressive spider naevi! The 50 year-old female patient on whom they were photographed presented having vomited blood, and passed-out at home. Her BP was unrecordable when the ambulance arrived, but rose to 76/43 by the time she reached hospital. She was known to have alcoholic liver disease and varices.
1. Other than standard resuscitation (ABC, cannulation, cross-match etc), what specific therapeutic interventions can be considered prior to endoscopy?
Click to see the answerBoth terlipressin and octreotide have been shown to improve outcomes, when used in combination with endoscopic interventions (eg banding) for varices. Terlipressin is given as a 2mg bolus, octreotide as an infusion of 50 μg/hr. Terlipressin is a vasopressin analogue. It reduces splanchnic blood flow, and has fewer adverse cardiac effects than vasopressin. Octreotide reduces portal venous pressure. Proton pump inhibitors are also given to increase gastric pH, which is thought to help clot stability.
2. Her investigations included albumin of 23 g/l, bilirubin of 20 μmol/l, urea of 16.9 mmol/l and INR of 2.1. What would you do about the INR?
Click to see the answerIn the context of life threatening bleeding (eg variceal, haemorrhagic stroke etc) it is generally wise to restore clotting to normal as quickly as possible. Giving Vit K will allow faster formation of clotting agents by the liver, but this takes many hours for full reversal, and is less effective in liver disease. Fresh frozen plasma (FFP) works quickly. It needs to be ABO group matched to the patient, and thawed before use. Generally four units are given before rechecking the INR. However in general FFP has been superseded by Prothrombin Complex Concentrate (eg Beriplex), at 30 units/Kg (eg 2000 units for a typical adult, equals four ampoules at £300 each, over at least ten minutes).
3. Why is the urea raised?
Click to see the answerThis patient would be expected to have a low urea level normally. Urea is synthesised from ammonia in hepatocytes via the urea cycle. In severe liver disease urea production is reduced and ammonia levels rise. However after an intestinal bleed, the blood acts as a protein meal, leading to raised urea levels.