Gastrointestinal Bleeding Viva

Long Case Viva Defence

Candidate's opening statement (model answer)

"Mr Huang is a 62-year-old man who presents with two large episodes of haematemesis and melaena over the past eight hours. He has a background of alcohol-related cirrhosis (Child-Pugh B), type 2 diabetes, hypertension, and a prior variceal bleed two years ago for which he had endoscopic band ligation. ^[1]

On examination he is tachycardic at 112, blood pressure 96/60 with a postural drop, cool peripheries, and he has stigmata of chronic liver disease — spider naevi, palmar erythema, and a small amount of ascites. Rectal examination confirms melaena. ^[1]

His main problems are:

1. Acute upper GI haemorrhage — most likely variceal rebleed, but peptic ulcer remains in the differential
2. Haemodynamic shock requiring resuscitation
3. Decompensated cirrhosis (Child-Pugh B) with portal hypertension
4. Type 2 diabetes and hypertension ^[1]

My immediate priority is resuscitation, then risk-stratification, then definitive endoscopic therapy within 12 hours for suspected variceal bleeding." ^[1]

Examiner probing questions and model answers

Q1: "Walk me through your resuscitation and pharmacotherapy in the first hour." ^[1]

"Two large-bore cannulae, cross-match four units, FBC, U&E, LFTs, coagulation, and a crystalloid bolus — but I will resuscitate judiciously in cirrhosis, because over-resuscitation raises portal pressure and worsens variceal bleeding. I will transfuse red cells restrictively — threshold haemoglobin 70 g/L, target 70 to 90 g/L — based on Villanueva et al. (NEJM 2013), which showed improved survival with a restrictive strategy. Because this is a suspected variceal bleed, I will start a vasoactive drug immediately — terlipressin 2 mg IV every four hours — and prophylactic ceftriaxone 1 g IV daily. Antibiotics reduce mortality in cirrhotic GI bleeding (Bernard 1999). I will then arrange endoscopy within 12 hours." ^[1]

Q2: "Why terlipressin rather than octreotide?" ^[1]

"Terlipressin is the only vasoactive agent shown in meta-analysis to reduce mortality in acute variceal bleeding — the Ioannou Cochrane review (2003). It is a vasopressin analogue causing splanchnic vasoconstriction, reducing portal inflow and pressure. Octreotide is a reasonable alternative where terlipressin is unavailable or contraindicated (for example, in severe peripheral or mesenteric ischaemia), but the mortality signal is strongest for terlipressin. Both reduce portal pressure as a bridge to definitive endoscopic therapy." ^[1]

Q3: "How will you use the Glasgow-Blatchford and Rockall scores in this patient?" ^[1]

"The Glasgow-Blatchford Score is calculated before endoscopy and predicts the need for intervention. His will be high given the deranged observations and low blood pressure, confirming he needs admission and urgent endoscopic therapy. The Rockall score is calculated after endoscopy and predicts mortality and rebleeding — it incorporates age, shock, comorbidity, diagnosis, and stigmata of recent haemorrhage. With cirrhosis as a major comorbidity plus shock, his Rockall will be high regardless of endoscopic findings, which tells me he needs a high level of care and close monitoring for rebleeding." ^[1]

Q4: "Endoscopy shows active bleeding from an oesophageal varix. What is your endoscopic therapy, and what if it fails?" ^[1]

"Endoscopic variceal ligation (banding) is first-line — Stiegmann et al. (NEJM 1992) showed it is as effective as sclerotherapy with fewer complications. I would band the bleeding varix and any other large varices in the distal oesophagus. If bleeding is uncontrolled or recurs despite banding and ongoing vasoactive therapy, I would consider balloon tamponade (Sengstaken-Blakemore) strictly as a temporary bridge for up to 24 hours, and arrange an urgent transjugular intrahepatic portosystemic shunt (TIPS). In fact, in a high-risk cirrhotic like this — Child-Pugh B with active bleeding — early pre-emptive TIPS within 72 hours is recommended to reduce treatment failure and mortality." ^[1]

Q5: "He is on apixaban for atrial fibrillation. How does that change things?" ^[1]

"Taking this as a variation where he is also anticoagulated — if Mr Huang were on apixaban for atrial fibrillation, I would withhold it immediately and discuss reversal with haematology for this life-threatening bleed — andexanet alfa or prothrombin complex concentrate. I would weigh his thrombotic risk (CHA2DS2-VASc) against bleeding and plan to resume anticoagulation within 7 to 14 days once haemostasis is secure. Premature permanent cessation is a common and harmful error in cirrhotic patients who often have high thrombotic risk." ^[1]

Q6: "What is his prognosis and how will you discuss it?" ^[1]

"Variceal bleeding is a marker of decompensated cirrhosis with significant one-year mortality — often 30 to 40 percent or higher depending on Child-Pugh grade and whether rebleeding or complications like infection and renal failure occur. I would discuss this honestly but constructively with Mr Huang and his family — explaining that the acute bleed can be controlled, that secondary prophylaxis with a non-selective beta-blocker and repeat banding reduces rebleeding, but that the underlying liver disease is the determining factor. I would initiate a transplant referral conversation early, as variceal bleeding is often the event that prompts transplant assessment." ^[1]