Portal Hypertension — Clinical Case

DCE Long Case

Patient brief (provided to trainee)

Patient: Mr David Nguyen, 58 years old, retired carpenter. ^[1]

Presenting complaint: Acute haematemesis (approximately 500 mL of fresh blood) and melaena this morning, followed by presyncope. Brought by ambulance. ^[1]

Past history:

• Alcohol-related cirrhosis diagnosed 3 years ago — current alcohol intake 60 grams/day (reduced from 100 g/day), has not engaged with alcohol services
• Large oesophageal varices (last OGD 6 months ago) — on carvedilol 12.5 mg OD for primary prophylaxis
• Mild ascites — on spironolactone 100 mg OD
• Hypertension, diet-controlled type 2 diabetes
• No prior hepatic encephalopathy, no known HCC ^[1]

Current medications:

• Carvedilol 12.5 mg OD
• Spironolactone 100 mg OD
• Thiamine 100 mg OD ^[1]

Examination findings (trainee elicits):

• Conscious, alert but pale, cool peripheries, capillary refill 4 seconds
• BP 86/52, HR 118 (regular), RR 22, SpO2 96 percent on room air, temp 36.8
• Spider naevi on anterior chest wall, palmar erythema, parotid enlargement, bilateral Dupuytren contracture, no gynaecomastia
• Abdomen: distended with shifting dullness (moderate ascites), spleen palpable 3 cm below left costal margin, liver edge not palpable. No caput medusae visible. Bowel sounds present.
• Rectal examination: melaena
• No asterixis, no obvious encephalopathy
• Bilateral pitting oedema to mid-shin ^[1]

Investigations:

• Hb 58 g/L (baseline 108 from 2 months ago), platelets 72, INR 1.7
• Na 131, K 4.2, creatinine 95 (baseline 80), urea 12.5
• Bilirubin 65, ALT 45, ALP 140, albumin 26
• Glucose 7.2
• Lactate 2.8
• Blood group O positive, cross-match requested, 4 units ^[1]

Candidate's structured presentation (model)

Opening statement: ^[1]

"Mr Nguyen is a 58-year-old retired carpenter who presents with an acute upper gastrointestinal haemorrhage — haematemesis and melaena with presyncope — in the context of known alcohol-related cirrhosis and large oesophageal varices. He is currently on carvedilol for primary prophylaxis of variceal bleeding. ^[1]

His main problems are:

1. Acute variceal haemorrhage with hypovolaemic shock — medical emergency
2. Decompensated alcohol-related cirrhosis — Child-Pugh B (score 9), MELD-Na approximately 19
3. High-risk bleeder (known large varices, Child-Pugh B) — consider pre-emptive TIPS
4. SBP risk requiring prophylactic antibiotics
5. Hepatorenal syndrome risk — monitor creatinine closely
6. Alcohol dependence — withdrawal prophylaxis and thiamine required
7. Malnutrition and sarcopenia
8. Liver transplant candidacy assessment needed ^[1]

My immediate priorities are: resuscitate with restrictive transfusion to haemoglobin 70 to 80, commence vasoactive therapy (terlipressin or octreotide) and prophylactic ceftriaxone immediately, proceed to urgent endoscopy within 12 hours for band ligation, assess for pre-emptive TIPS eligibility as he is a high-risk bleeder, and simultaneously plan for alcohol withdrawal prophylaxis, HRS surveillance, and transplant referral." ^[1]

Integrated management plan

1. Resuscitation and acute bleeding management: ^[1]

• Airway protection: consider intubation if ongoing haematemesis or reduced conscious state
• Restrictive transfusion: target haemoglobin 70 to 80 g/L (he is at 58 — transfuse 2 units of packed red cells). Avoid over-transfusion — raises portal pressure and worsens rebleeding
• Vasoactive therapy: terlipressin 2 mg IV every 4 hours (or octreotide 50 mcg bolus then 50 mcg/hour infusion). Start immediately, before endoscopy. Continue for 2 to 5 days
• Prophylactic antibiotics: ceftriaxone 1 g IV daily for 7 days — reduces mortality, not just infection. Essential in all cirrhotic patients with GI bleeding
• Urgent endoscopy within 12 hours: band ligation for oesophageal varices. If bleeding uncontrolled, balloon tamponade (Sengstaken-Blakemore) as bridge to TIPS
• Assess for pre-emptive TIPS: he is Child-Pugh B with known active variceal bleeding. Per Garcia-Pagan (PMID 20573925), patients with Child-Pugh C (10 to 13) or Child-Pugh B with active bleeding benefit from early TIPS within 72 hours — reduces treatment failure from 50 percent to 3 percent, improves one-year survival from 61 percent to 86 percent. I would discuss urgently with interventional radiology and hepatology ^[1]

2. Hepatorenal syndrome surveillance: ^[1]

• His creatinine is 95 (baseline 80) — not yet AKI but at high risk. Monitor creatinine every 12 to 24 hours
• If creatinine rises above 106 (meeting ICA-AKI criteria): stop diuretics, give albumin 1 g/kg/day for 2 days, then assess for HRS-AKI. Treat with terlipressin plus albumin if criteria met (CONFIRM trial, PMID 33657294)
• Check for SBP with diagnostic paracentesis — send PMN count, culture, albumin (SAAG) ^[1]

3. Alcohol withdrawal prophylaxis: ^[1]

• CIWA-Ar monitoring
• Diazepam or lorazepam protocol for withdrawal (hepatically metabolised agents at reduced doses; lorazepam preferred in significant liver dysfunction due to glucuronidation pathway)
• Continue thiamine 100 mg IV daily for 3 to 5 days to prevent Wernicke encephalopathy — give before any glucose
• Folate supplementation ^[1]

4. Longer-term management and transplant assessment: ^[1]

• Once bleeding controlled: secondary prophylaxis with NSBB plus serial EVL
• Liver transplant referral — calculate MELD-Na (currently approximately 19), assess abstinence (typically 6 months required), psychosocial evaluation
• Alcohol liaison team involvement — the single most important prognostic intervention for alcohol-related cirrhosis
• HCC surveillance: liver ultrasound plus AFP every 6 months
• Vaccinations: hepatitis A and B (if non-immune), influenza, pneumococcal, COVID-19
• Nutritional support: high-protein diet (1.2 to 1.5 g/kg/day), avoid fasting; dietician referral ^[1]

Examiner discussion questions

Q: "He is on carvedilol for primary prophylaxis and still bled. Does this mean the beta-blocker failed?" ^[1]

"Not necessarily — NSBB reduce but do not eliminate bleeding risk. Carvedilol reduces the risk of first variceal bleed by approximately 50 percent, but patients can still bleed, particularly if they have large varices with red signs or if the HVPG is not reduced below 12 mmHg (the bleeding threshold). The fact that he bled despite NSBB means he now requires secondary prophylaxis, which is combination therapy with NSBB plus serial EVL — this is more effective than either alone. I would also verify adherence and whether his carvedilol dose was adequate — 12.5 mg daily is a reasonable dose, but some patients require dose titration based on heart rate response. Once the acute episode resolves, I would recommence NSBB (continuing carvedilol or switching to propranolol or nadolol) combined with serial EVL every 2 to 4 weeks until variceal eradication." ^[1]

Q: "How would you decide between terlipressin and octreotide as the vasoactive agent?" ^[1]

"Terlipressin is the preferred agent where available. It is a synthetic vasopressin analogue with greater evidence for efficacy in both acute variceal bleeding and hepatorenal syndrome. Meta-analyses show terlipressin reduces all-cause mortality compared to placebo in acute variceal bleeding, while octreotide has more mixed evidence. However, terlipressin is not available in all centres or countries — it was only FDA-approved in the US in 2022 (as Terlivaz), and octreotide remains more widely used there. In ANZ and the UK, terlipressin is available and preferred. Both work by causing splanchnic vasoconstriction, reducing portal inflow and pressure. Key contraindications to terlipressin include ischaemic heart disease, peripheral vascular disease, and volume overload with hypoxia (due to the respiratory failure risk highlighted in the CONFIRM trial). Octreotide is generally better tolerated with fewer ischaemic side effects." ^[1]

Q: "He develops SBP (PMN 380). How does this change his management?" ^[1]

"SBP is both a complication and a precipitant of further decompensation, including hepatorenal syndrome. I would: continue ceftriaxone 1 g IV daily for 5 to 7 days; give intravenous albumin 1.5 g/kg on day 1 and 1 g/kg on day 3 (Sort trial, PMID 10432325 — reduces renal impairment from 33 to 10 percent and in-hospital mortality from 29 to 10 percent); repeat paracentesis at 48 hours to confirm PMN is falling by at least 25 percent; monitor renal function closely as SBP is a common trigger for HRS-AKI. After recovery, commence secondary SBP prophylaxis with norfloxacin 400 mg orally daily indefinitely — the one-year recurrence rate without prophylaxis is 70 percent." ^[1]

Q: "What is his prognosis and how would you discuss transplantation?" ^[1]

"His prognosis depends critically on whether he can maintain alcohol abstinence. After a variceal bleed, the one-year mortality is 30 to 40 percent for patients who continue drinking, but drops substantially for those who abstain and achieve recompensation. His MELD-Na of approximately 19 predicts a 90-day mortality of approximately 6 to 10 percent with optimal management, but this rises if he develops further complications (HRS, SBP, recurrent bleeding). I would initiate liver transplant assessment immediately — the indications are his decompensation events (bleeding, ascites). For alcohol-related cirrhosis, most Australian transplant centres require 6 months of documented abstinence, though this is increasingly individualised based on psychosocial assessment rather than a rigid timeframe. I would involve the alcohol liaison team, hepatology, transplant surgery, social work, and psychiatry. I would discuss prognosis honestly — emphasising that abstinence is the single most important prognostic factor, that transplant is the definitive treatment for decompensated cirrhosis, and that advance care planning is appropriate if he is not a transplant candidate." ^[1]