A 55-year-old man with a history of decompensated alcohol-related cirrhosis is brought to the emergency department after vomiting a large amount of bright red blood. On arrival, his blood pressure is 85/50 mmHg, and his heart rate is 122/min. He appears pale and lethargic but is maintaining his airway.
Arrange the following management steps in the most appropriate chronological sequence for this patient's acute condition.
- 1Establish two large-bore peripheral intravenous lines for volume resuscitation
- 2Administer intravenous octreotide and prophylactic ceftriaxone
- 3Perform urgent esophagogastroduodenoscopy (EGD) for targeted therapy
- 4Consider placement of a transjugular intrahepatic portosystemic shunt (TIPS)
Cevap
The correct sequence of steps for managing acute suspected variceal hemorrhage is: establish IV access for volume resuscitation, administer IV octreotide and prophylactic antibiotics, perform urgent EGD for band ligation, and consider TIPS if bleeding is refractory.
The management of acute variceal hemorrhage follows a strict algorithmic approach prioritizing the ABCs. The patient is in hypovolemic shock, so establishing large-bore IV access for fluid (and subsequent blood product) resuscitation is the immediate first step. Following access, medical therapy with a splanchnic vasoconstrictor (octreotide) and prophylactic antibiotics (ceftriaxone) is initiated to reduce portal pressure and prevent infection. Once the patient is medically optimized, an urgent EGD is performed (typically within 12 hours) to identify the source and perform endoscopic band ligation. Finally, if bleeding persists or recurs despite medical and endoscopic therapy, a transjugular intrahepatic portosystemic shunt (TIPS) is placed as a salvage intervention.
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Anahtar Kavram
Algorithm for acute variceal hemorrhage management in cirrhosis