The Case of the Middle-Aged General With a Fatal Postnuptial Hemorrhage

Albert B. Lowenfels, MD; Doris B. Lowenfels, MLS

Disclosures

April 20, 2006

How Would This Patient Be Diagnosed and Treated Today?

Examination of the anterior and posterior nasal fossae would quickly reveal whether the source of bleeding came from the nasal passages. If the bleeding came from the nose, nasal packing along with cauterization would control it. If the nosebleed was associated with hypertension, than an antihypertensive agent would be indicated.

Assuming that the bleeding did not come from the nose, then the next step would be endoscopy of the esophagus, stomach, and duodenum. If, as is likely, the bleeding came from esophageal varices, several therapeutic options are available. Portocaval and splenorenal shunts were common procedures during most of the second part of the 20th century, but have generally been replaced by endoscopic procedures, such as ligation or endoscopic sclerotherapy, or by intrahepatic portosystemic shunt procedures.[5] Although a variety of measures are available to treat this often fatal cause of digestive tract hemorrhage, we still do not have a satisfactory therapeutic solution. The most definitive procedure is liver transplantation -- an option only for patients who demonstrate a sustained period of sobriety -- and so would not have been available to Attila if he were alive today.[6,7,8]

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