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LEARNING OBJECTIVES

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

  • 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.

PATIENT PRESENTATION

Chief Complaint

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

HPI

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.

PMH

  • 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)

FH

Father with CAD and CABG; no other history known.

SH

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.

ROS

Negative except for complaints noted in HPI.

Meds

  • 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)

All

NKDA

Physical Examination

Gen

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

VS

BP 108/60, P 120, RR 14, T 37.8°C

Skin

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

HEENT

PERRLA; icteric sclerae

Neck/Lymph Nodes

Neck supple; no masses

Lungs/Thorax

Clear to auscultation bilaterally

Breasts

No lumps or masses

CV

Tachycardia, RRR, no M/R/G

Abd

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

Rect

Frank blood

Ext

Bilateral 1+ pedal edema

Neuro

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