Chapter 46: Esophageal Varices: Banding the Bleeding Level II

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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 alcohol abuse

History of hepatic encephalopathy

Ascites with history of paracentesis

Peptic ulcer disease

Hypertension

Cellulitis (two admissions in the past 3 years)

FH

Father with CAD and CABG; no other history known

SH

The patient lives alone and has been able to function independently. Quit drinking 5 years ago. Previously drank 6 beers per weekday and 750 mL of liquor on weekends. Quit smoking 3 years ago (35 pack-year history). She works as an accountant.

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)

Bupropion XL 300 mg daily

Lactulose 20 g PO Q6H

All

NKDA

ROS

Negative except for complaints noted in HPI

Physical Examination

Gen

Obese woman 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