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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • List nonpharmacologic options for managing patients with bleeding esophageal varices.

  • Recommend appropriate pharmacologic therapy for controlling bleeding esophageal varices and adjunctive therapy in the setting of acute variceal bleeding.

  • Provide appropriate education for patients receiving therapy for portal hypertension.

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PATIENT PRESENTATION

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Chief Complaint

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“I’ve been throwing up blood, enough to fill my bathroom sink!”

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HPI

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Ethyl Johnson is a 55-year-old woman who presents to the ED with complaint of vomiting blood and bright red blood per rectum. She was in her usual state of health, until shortly after taking a dose of lactulose when she began to feel sick and subsequently vomited a large amount of blood into the bathroom sink. She also reports a 2-day history of BRBPR.

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PMH

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  • Cirrhosis secondary to hepatitis C (acquired from a blood transfusion in 1980s)

  • Hepatic encephalopathy

  • Hepatitis C

  • Peptic ulcer disease

  • Hypertension

  • Cellulitis (two admissions in the past 3 years)

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FH

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Father with CAD and CABG; no other history known.

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SH

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She lives alone and has been able to function independently. Quit smoking 10 years ago and does not drink alcohol. She works as an accountant.

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ROS

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Negative except for complaints noted in HPI.

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Meds

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  • Sucralfate 1 g PO BID

  • Omeprazole 20 mg PO BID

  • Bumetanide 1 mg PO BID

  • Spironolactone 50 mg PO once daily

  • Propranolol 40 mg PO BID (may not be taking)

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All

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NKDA

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Physical Examination

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Gen
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Obese female looking older than stated age, looks somnolent but occasionally moves head

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VS
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BP 108/60, P 120, RR 14, T 37.8°C

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Skin
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Some spider angiomas on abdomen, thick skin, chronic venous stasis changes with lichenification

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HEENT
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PERRLA; icteric sclerae

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Neck/Lymph Nodes
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Neck supple; no masses

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Lungs/Thorax
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Clear to auscultation bilaterally

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Breasts
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No lumps or masses

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CV
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Tachycardia, RRR, no M/R/G

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Abd
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Obese, mildly distended, distant bowel sounds present, difficult to assess for hepatosplenomegaly

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Rect
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Frank blood

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Ext
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Bilateral 1+ pedal edema

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Neuro
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Sleepy, moves head occasionally; is arousable and oriented × 3; no asterixis

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Labs (on Admission)

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