A Severe Case of Hematemesis: Find the Differences

SECTION 1 – QUIZ Case A 77-year-old male presented to the emergency department (ED) following two episodes of large-volume hematemesis and overt hepatic encephalopathy. He had been followed at an outpatient hepatology clinic for liver cirrhosis (Child-Pugh A), of mixed metabolic and alcoholic etiology, with a history of variceal bleeding, submitted to band ligation and carvedilol therapy for secondary prophylaxis. Over the past year, the patient’s liver disease has remained stable. He underwent biannual abdominal ultrasound and annual upper endoscopy as part of routine surveillance. His most recent abdominal ultrasound, 5 months before presentation, showed a dilated but patent portal vein [Figure 1]. His latest upper endoscopy, 3 months prior, confirmed eradicated esophageal varices without stigmata of recent or impending bleeding.Figure 1: Ultrasound 5 months before presentationOn arrival at the ED, his blood pressure was 105/68 mmHg, and his heart rate was 94 bpm. Initial evaluation showed visible blood in the oral cavity, tachypnea requiring oxygen supplementation at 4 L/min via nasal cannula, and the following arterial blood gas results: pH 7.26, bicarbonate 17.7 mmol/L, lactate 6.2 mmol/L, and hemoglobin 10 g/dL. Subsequently, the patient was transferred to the emergency room. Orotracheal intubation was performed to prevent aspiration, along with volume resuscitation (normal saline), terlipressin 2 mg, and ceftriaxone 1g administration. Following hemodynamic stabilization, he underwent upper gastrointestinal endoscopy. At 36 cm from the incisors, an actively bleeding esophageal varix was identified and successfully treated with elastic band ligation. Previously eradicated esophageal varices were noted to have become dilated and exhibited red spots, having a markedly different appearance when compared to his last endoscopy. Postprocedure, the patient was admitted to the intensive care unit (ICU). After adequate stabilization, on the 2nd day of his ICU stay, a point-of-care Color Doppler ultrasonography was performed to screen for ascites and portal vein thrombosis. Figure 2 shows the point-of-care ultrasound findings.Abbreviations ED Emergency Department ICU Intensive Care UnitFigure 2: Point-of-care ultrasound with color Doppler in the intensive care unitWhat is the most likely cause of this acute decompensation? Ethics statement This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and its amendments. The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.