virgola82
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A 43 yoman is admitted with variceal bleeding. He has a history of cirrhosis due to hepatitis C. two years ago he was treated with 6 mo of pegylated inteferon and ribavirin but remained HCV RNA +. subsequently he felt well until today at 1 AM when he had hematemesis. EGD in the emergency department showed esophageal varices, which were ligated. He has had neither fluid retention nor encephalopathy. Physical exam findings are notable for the following. BP 110/56 mmHg, HR 72, alert and oriented, splenomegaly, and no ascites or edema. Lab studies show Hb 12.2 g/L, Plt 65000/microL AST 84, ALT 75, tot bilirubin 1.2 mg7dl, albumin 3.1 g/dl, INR 1.2. Abdominal ultrasound shows no liver masses a patent portal vein splenomegaly and no ascites. Which of the following would you advise now?
A. Use a transjugular intrahepatic portosystemic shunt (TIPS)
B. Give Norfloxacin
C. Transfuse packe RBCs
D. Transfuse fresh frozen plasma
E. Initiate pegylated interferon maintenance therapy
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| sprint123
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"FFP is administered whenever there is active bleeding"
I will go with D
Norfloxacin can be given as a prophylaxis to prevent SBP if ascites is present
TIPS is done as a last measure to relieve ascites
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| arlete
Attending in 2012!!!!!
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I think the best is D, but is the bleeding really active, even after ligation?
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| dr in trouble
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I think FFP is indicated when platelet count is below 50,000 and there is no sign of continous bleeding because pt is stable.
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| ashfaque
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A)) TIPS is used to dec the portal hypertension and is done as emergency procedure.
ffps r indicated when INR pt aptt is deranged which is not the case.
patient had bleeding due to portal hypertension and esophageal varices not bc of coagulopathy plus question is giving us the clue that patient is not in encephalopathy means TIPs can be performed in presence of enceph TIPs is contraindicated
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| ashfaque
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CLD patient bleed either bc of deranged pt and aptt or vriceal bleed due to prtal hypertension not bc of thrombocytopenia
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| ashfaque
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recurrent \ refractory vriceal bleed is one the indication of tips as n this case
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| sprint123
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I agree with you that bleeding occurs due to coagulopathy----But TIPS is indicated only in refractory UGI bleed--In this case it is controlled by banding...
I am having a second thought of Prophylactic Norfloxacin to prevent sepsis due to the ligation procedure?!
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| virgola82
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The right answer is Norfloxacin.
Prophilactic therapy for spontaneous bacterial peritonitis is recommended for all patients with a previous episode of SBP with norfloxacin 400 mg/day indefinitely, for every patient with cirrhosis hospitalized for a GI bleed regardless of whether ascites or SPB are present at the moment with norfloxacin 400mg/day for 7 days ,and for patients with cirrhosis hospitalized for any reason and having an ascitic fluid protein concentration < 1g/dl with norfloxacin 400 mg/day until hospital discharge
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| arlete
Attending in 2012!!!!!
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Good question!
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| sailing boat
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good one
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| gk333
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good 1
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