A 61-year-old man with hematemesis and signs of chronic liver disease (gynecomastia, spider nevi) has anemia, hypoxemia, hypotension, and tachypnea after initial fluid resuscitation; what is the next step in management?

Management of Hematemesis in a Patient with Chronic Liver Disease

After initial fluid resuscitation in this patient with hematemesis and signs of chronic liver disease, the next step is upper GI endoscopy (Option D), which serves both diagnostic and therapeutic purposes for suspected variceal bleeding.

Rationale for Upper GI Endoscopy

Upper endoscopy should be performed after initial resuscitation and hemodynamic stabilization, as it is both diagnostic and therapeutic for variceal bleeding. 1 The patient's clinical presentation—gynecomastia, spider nevi, and hematemesis—strongly suggests esophageal variceal bleeding secondary to portal hypertension from cirrhosis. 2

• Endoscopic therapy (preferably band ligation) combined with vasoactive drugs represents the standard of care for acute variceal bleeding, reducing mortality from 50% to 10-20%. 2, 3
• The American College of Radiology guidelines emphasize that vasoactive pharmacologic agents should be initiated first, followed by endoscopic therapy after initial resuscitation when the patient is stable and bleeding has slowed or ceased. 1
• Endoscopy should be performed within 24 hours of presentation in patients with evidence of ongoing bleeding or high-risk features. 1

Why Not the Other Options

Blood transfusion (Option A) is premature at this stage. The patient's hemoglobin is 85 g/L (8.5 g/dL), which is above the recommended transfusion threshold for variceal bleeding.

• In patients with cirrhosis and acute variceal bleeding, a restrictive transfusion strategy targeting hemoglobin >7 g/dL (70 g/L) improves survival in Child-Pugh A and B patients. 1
• Over-transfusion can exacerbate portal pressure, impair clot formation, and increase rebleeding risk. 1
• The current hemoglobin of 85 g/L does not mandate immediate transfusion unless there is massive ongoing bleeding or cardiovascular instability despite resuscitation. 1

Nasogastric tube placement (Option B) is not routinely recommended. While NGT can help assess ongoing bleeding, it does not change management and may cause patient discomfort without clear benefit.

• Modern guidelines do not mandate NGT placement before endoscopy in suspected variceal bleeding. 1
• The diagnosis can be established directly by endoscopy, which is both more definitive and therapeutic. 1

Selective angiography (Option C) is reserved for refractory cases. This is not a first-line intervention after initial resuscitation.

• Angiographic interventions are considered when standard medical and endoscopic therapy fails to control bleeding. 3
• Transjugular intrahepatic portosystemic shunt (TIPS) is recommended for variceal bleeding refractory to endotherapy, not as initial management. 2, 3

Critical Management Principles

Vasoactive drugs should be started immediately upon suspicion of variceal bleeding, even before endoscopy. 1

• Early administration of vasoactive agents (somatostatin, terlipressin, or octreotide) facilitates endoscopy, improves early hemostasis, and lowers 5-day rebleeding rates. 1
• Combined endoscopic plus vasoconstrictor treatment achieves 77% 5-day hemostasis compared to 58% with endoscopy alone. 1

Antibiotic prophylaxis should be administered to all hospitalized patients with cirrhosis and acute GI bleeding. 1

• Prophylactic antibiotics reduce mortality (RR 0.79), bacterial infections (RR 0.40), and rebleeding in patients with cirrhosis and acute GI hemorrhage. 1

Avoid fluid overload during resuscitation. 1

• Target mean arterial pressure >65 mmHg while avoiding over-expansion, which can exacerbate portal pressure and increase bleeding risk. 1
• A certain degree of controlled hypotension promotes splanchnic vasoconstriction, reducing portal blood flow and pressure. 1

Common Pitfalls to Avoid

• Do not delay endoscopy to correct coagulation parameters. The INR elevation in cirrhosis reflects rebalanced hemostasis, not true bleeding risk, and prophylactic correction with FFP or platelets is not indicated. 1
• Do not over-transfuse blood products. Excessive transfusion worsens portal hypertension and increases mortality. 1
• Do not assume all upper GI bleeding in cirrhosis is variceal. Up to 8% may have upper non-variceal sources, making endoscopic diagnosis essential. 1