Portal Hypertension — SAQ

Stem

A 52-year-old man with known alcoholic cirrhosis (Child-Pugh B) presents with massive haematemesis. BP 80/50, HR 128. He is pale, clammy, and confused.^[2]

Questions

a) Outline the immediate management in order of priority. (4 marks)

1. AIRWAY protect (intubate if encephalopathic or uncontrolled haemorrhage)
2. CIRCULATION two large-bore cannulae; restrictive transfusion — transfuse when haemoglobin falls under 7 g/dL, targeting 7–8 g/dL^[7][2]
3. VASOACTIVE DRUG start as soon as variceal haemorrhage is suspected, before endoscopy, and continue 2–5 days (terlipressin 2 mg IV every 4 hours is a standard bolus regimen; octreotide is the safety-first alternative)^[10][11]
4. ANTIBIOTIC PROPHYLAXIS from admission — integral to the bleed bundle. Intravenous ceftriaxone 1 g/24 h is considered in advanced cirrhosis and in settings with high quinolone resistance. A 2025 meta-analysis found shorter or no prophylaxis noninferior for all-cause mortality, so do not quote a 10% mortality reduction^[2][16]
5. URGENT OGD within 12 hours for endoscopic variceal ligation (sooner if unstable)^[2]

b) The bleeding is controlled with EVL. What secondary prophylaxis is needed to prevent rebleeding? (2 marks)

Combination traditional NSBB or carvedilol plus serial EVL until varices are eradicated. Untreated 1- to 2-year rebleeding is about 60%. TIPSS if rebleeding occurs despite combination therapy. Consider liver transplant once the patient is decompensated.^[2][18]

c) Bleeding recurs despite combination therapy. What definitive rescue procedure is indicated, and what is its key complication? (2 marks)

TIPSS (PTFE-covered stent between portal and hepatic veins). In refractory bleeding it is salvage therapy; balloon tamponade or a covered metal stent is only a bridge. Versus paracentesis for refractory ascites, TIPS more than doubles hepatic encephalopathy (odds ratio 2.24). Manage encephalopathy with lactulose and rifaximin 550 mg twice daily.^[2][15][9]

d) What is the significance of the Child-Pugh B classification in this patient, and does it affect the acute bleed management? (2 marks)

Child-Pugh B is 7–9 points. Baveno VII pre-emptive TIPSS (within 72 hours, ideally under 24 hours) is indicated for Child-Pugh C under 14, or Child-Pugh B greater than 7 with active bleeding at initial endoscopy, or HVPG over 20 mmHg — not for every class-B bleeder. The Early TIPS trial used class C or class B with persistent bleeding at endoscopy. Flag this patient for pre-emptive TIPSS if endoscopy shows active bleeding and the B score is greater than 7.^[2][3]

References9ShowHide

1. [2]de Franchis R, Bosch J, Garcia-Tsao G, et al. Baveno VII - Renewing consensus in portal hypertension J Hepatol, 2022.PMID 35120736
2. [3]García-Pagán JC, Caca K, Bureau C, et al. Early use of TIPS in patients with cirrhosis and variceal bleeding N Engl J Med, 2010.PMID 20573925
3. [7]Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding N Engl J Med, 2013.PMID 23281973
4. [9]Bass NM, Mullen KD, Sanyal A, et al. Rifaximin treatment in hepatic encephalopathy N Engl J Med, 2010.PMID 20335583
5. [10]Garcia-Tsao G, Abraldes JG, Rich NE, et al. AGA Clinical Practice Update on the Use of Vasoactive Drugs and Intravenous Albumin in Cirrhosis: Expert Review Gastroenterology, 2024.PMID 37978969
6. [11]Arora V, Choudhary SP, Maiwall R, et al. Low-dose continuous terlipressin infusion is effective and safer than intravenous bolus injections in reducing portal pressure and control of acute variceal bleeding Hepatol Int, 2023.PMID 36542261
7. [15]Saab S, Nieto JM, Lewis SK, et al. TIPS versus paracentesis for cirrhotic patients with refractory ascites Cochrane Database Syst Rev, 2006.PMID 17054221
8. [16]Prosty C, Noutsios D, Dubé LR, et al. Prophylactic Antibiotics for Upper Gastrointestinal Bleeding in Patients With Cirrhosis: A Systematic Review and Bayesian Meta-Analysis JAMA Intern Med, 2025.PMID 40788637
9. [18]de Franchis R, Primignani M Natural history of portal hypertension in patients with cirrhosis Clin Liver Dis, 2001.PMID 11565135