Author: Thang Le, MDSeries Editor: Richard Goodgame, MD


October 20, 2003

Case Presentation

A 44-year-old man presented with hematemesis.

The patient has a history of hepatitis C and alcohol-related cirrhosis. He has had multiple episodes of hematemesis due to esophageal variceal bleeding during the past 2 years. He was treated with propranolol and variceal obliteration with band ligation, but continued to require hospitalization for acute bleeding. He was admitted 8 months ago and refused to have transjugular intrahepatic portosystemic shunt (TIPS) placement.

Six months ago he had another episode of hematemesis. His acute bleeding was controlled with octreotide and endoscopic band ligation. He had no encephalopathy but had mild ascites. At that time, his bilirubin level was 1.2 mg/dL; albumin level, 2.2 g/dL; international normalized ratio (INR), 1.2; and creatinine level, 1.5 mg/dL. He drank alcohol on weekends. The patient had elective TIPS placed; the portosystemic gradient went from 18 mmHg to 10 mmHg. He was instructed to stop drinking entirely. He was doing well until 1 day prior to this admission when he had 2 episodes of coffee-ground emesis and 1 episode of hematemesis, which was about one-half cup of bright red blood. He noted melena, but denied hematochezia.

His past medical history is positive for intravenous-drug use 20 years ago, heavy alcohol abuse until 3 years ago, and hepatitis C infection diagnosed 3 years ago. Cirrhosis was diagnosed clinically 3 years ago. His first variceal bleed occurred 2 years ago. His medications included propranolol, spironolactone, pantoprazole, and multiple vitamins. There was no history of cardiac, pulmonary, or renal disease, and no family history of liver disease. He continued to drink alcohol on weekends.

Physical examination showed normal vital signs while lying down but postural changes in pulse and blood pressure (before resuscitation). He had palmar erythema and spider angiomata. The peripheral pulses were normal. There was no jugular venous distension. The heart was normal to palpation and auscultation. The lungs were normal. The abdomen was mildly distended and the flanks were bulging. There was mild shifting dullness. The spleen was felt 3 cm below the left costal margin. The liver edge was firm and irregular. There was no peripheral edema. Mental status was normal.

Results of routine laboratory studies were normal except for the following:

Hemoglobin: 7 g/dL
Blood urea nitrogen: 26 mg/dL
Creatinine: 1.5 mg/dL
Total protein: 5 g/dL
Albumen: 2.2 g/dL
Total bilirubin: 1.5 mg/dL
Direct bilirubin: 0.8 mg/dL
Alkaline phosphatase: 183 U/L
Alanine aminotransferase: 145 U/L
Aspartate aminotransferase: 113 U/L
INR: 1.3