58 year old man brought in by ambulance to the Emergency Department Resus after vomiting bright red blood.

The vomiting started abruptly after eating lunch. He has a long drinking history. He currently drinks ½ bottle vodka per day and about ½ case Carlsberg per day. He recently lost his driving licence for drink driving and is under performance observation at his job as an accountant. His marriage is also under strain due to his drinking. He has had a previous admission to hospital with a Mallory-Weiss tear and is known to his GP because of his high alcohol intake. He is otherwise well and has no other significant PMH.

On examination he looks unwell, is shocked and is still actively vomiting blood. There is evidence of chronic liver disease on examination.

Observations

  • HR – 120 regular

  • BP – 60/30

  • RR – 20

  • Sats – 98% OA

  • GCS – 14/15

The assessing team as concerned that the patient has an acute variceal bleed.

  • Hb – 64

  • Lactate – 5.0

  • INR – 1.8

  • Platelets – 40

Questions

Answer one question before attending the face-to-face teaching session. Add comments to answers already given if you think it's appropriate. The first part of teaching will be spent discussing this case:

  1. What are oesophageal varices, why do they happen and what are the other anastomses in the body?
  2. Please give some differential diagnoses of upper GI bleeds?
  3. What would be your fluid management for this patient?
  4. How would you manage his haematological abnormalities?
  5. Name two other treatments specific for this patient, describe their mode of action and the evidence behind them?
  6. He starts profusely vomiting bright red blood and remains hypotensive despite repeated fluid boluses. What are your next management steps?
  7. When would this patient receive an OGD?

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