What is the History and Physical (H&P) for a patient with liver cirrhosis and upper gastrointestinal (GI) bleed?

From the Guidelines

The patient with liver cirrhosis and upper gastrointestinal (GI) bleed should undergo urgent endoscopy within 12 hours of admission to identify and treat the source of bleeding, and receive vasoactive drug therapy for 2-5 days to prevent early rebleeding, as recommended by the most recent guidelines 1. The patient presents to the emergency department with hematemesis, melena, and abdominal pain for the past 24 hours, and has a known history of alcohol-induced liver cirrhosis diagnosed 3 years ago, with previous episodes of hepatic encephalopathy and ascites.

Key Points to Consider:

• The patient's past medical history includes hypertension, type 2 diabetes, and a previous variceal bleed 1 year ago, and current medications include propranolol, furosemide, spironolactone, and metformin.
• On physical examination, the patient appears pale and diaphoretic with vital signs showing tachycardia, hypotension, and tachypnea, and abdominal examination reveals a distended abdomen with shifting dullness suggesting ascites, splenomegaly, and mild diffuse tenderness without rebound or guarding.
• Laboratory findings show hemoglobin 7.2 g/dL, platelets 65,000/μL, INR 1.8, total bilirubin 3.2 mg/dL, albumin 2.8 g/dL, creatinine 1.4 mg/dL, and BUN 32 mg/dL, and the MELD-Na score is calculated at 18.
• Initial management includes two large-bore IV access, fluid resuscitation with normal saline, blood type and cross for 2 units PRBC, IV octreotide 50mcg bolus followed by 50mcg/hr infusion, and IV ceftriaxone 1g daily for SBP prophylaxis, as supported by previous guidelines 1.
• The use of vasoactive drugs, such as octreotide, has been shown to improve clinical outcomes in patients with AVH, including reduced 7-day mortality, improved hemostasis, and shortened hospitalization 1.
• The patient requires close monitoring in the ICU setting with serial hemoglobin checks, and potential administration of vitamin K and fresh frozen plasma to correct coagulopathy, as recommended by recent guidelines 1.

From the Research

History and Physical (H&P) for Liver Cirrhosis and Upper GI Bleed

The history and physical examination for a patient with liver cirrhosis and upper gastrointestinal (GI) bleed typically involve assessing the patient's overall condition, identifying the source of bleeding, and evaluating the severity of the bleed.

• The patient's medical history, including the presence of liver disease, previous episodes of GI bleeding, and any underlying conditions that may contribute to bleeding, such as coagulopathy or thrombocytopenia, should be reviewed 2, 3.
• A physical examination should be performed to assess the patient's vital signs, including blood pressure, heart rate, and oxygen saturation, as well as to evaluate for signs of bleeding, such as melena or hematemesis 4.
• Laboratory tests, including complete blood count, coagulation studies, and liver function tests, should be ordered to evaluate the patient's hemostatic competence and liver function 5, 6.

Sources of Upper GI Bleed in Liver Cirrhosis

The sources of upper GI bleed in patients with liver cirrhosis can vary, but common causes include:

• Esophageal varices, which are dilated veins in the esophagus that can rupture and cause bleeding 4.
• Gastric and duodenal ulcers, which can erode into blood vessels and cause bleeding 4.
• Congestive gastropathy, which is a condition characterized by dilated blood vessels in the stomach that can cause bleeding 4.
• Hemostatic failure, which can occur due to coagulopathy or thrombocytopenia 3, 5.

Management of Upper GI Bleed in Liver Cirrhosis

The management of upper GI bleed in patients with liver cirrhosis typically involves:

• Resuscitation with fluids and blood products, as needed, to stabilize the patient's vital signs and prevent shock 2, 5.
• Endoscopy to visualize the source of bleeding and potentially treat it with cauterization, clipping, or banding 4.
• Medications, such as somatostatin or octreotide, to reduce bleeding from esophageal varices 2.
• Transfusion of blood products, such as packed red blood cells, platelets, or fresh frozen plasma, to correct coagulopathy or thrombocytopenia 5, 6.