Instructors can request access to the Casebook Instructor's Guide on AccessPharmacy. Email User Services (firstname.lastname@example.org) for more information.
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.
“I’ve been throwing up blood, enough to fill my bathroom sink!”
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.
Cirrhosis secondary to alcohol abuse
History of hepatic encephalopathy
Ascites with history of paracentesis
Cellulitis (two admissions in the past 3 years)
Father with CAD and CABG; no other history known
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.
Spironolactone 50 mg PO once daily
Propranolol 40 mg PO BID (may not be taking)
Bupropion XL 300 mg daily
Negative except for complaints noted in HPI
Obese woman looking older than stated age, looks somnolent but occasionally moves head
BP 108/60, P 120, RR 14, T 37.8°C
Some spider angiomas on abdomen, thick skin, chronic venous stasis changes with lichenification
Clear to auscultation bilaterally