GI Bleed & ESLD: Child-Pugh C

What the Examiner Is Testing

This case tests TEG/ROTEM-guided resuscitation over empirical "shotgunning" of blood products. The examiner wants to see that you understand cirrhotic coagulopathy is complex — it's not just low INR — and that excessive FFP can worsen portal hypertension and bleeding.

The Board Trap

The trap is reflexively ordering large volumes of FFP because the INR is 2.8. In cirrhosis, the INR reflects thrombin generation but not the full picture — these patients also have low protein C and S, meaning they're in a rebalanced coagulopathy state. Flooding them with FFP increases portal pressure and can make variceal bleeding worse. The board answer is point-of-care testing to guide targeted replacement.

Walk-Through: How This Case Plays Out

Examiner: The patient is actively bleeding with a BP of 85/50. How do you manage the airway?

Me: My first priority is airway control. This patient has a stomach full of blood and is encephalopathic — aspiration risk is high. I would perform a rapid sequence induction with cricoid pressure. I'd use etomidate for induction to preserve hemodynamics, and succinylcholine for the fastest possible intubation. I'm not waiting to check coagulation before securing the airway.

Examiner: He's intubated. INR is 2.8, platelets 45k. How do you manage his coagulopathy?

Me: I would send a TEG or ROTEM immediately. I don't want to give products based on INR alone in a cirrhotic — it doesn't tell me enough. If the TEG shows a clot initiation problem, I'd give cryoprecipitate for fibrinogen or 4-factor PCC. If there's a platelet function problem, I'd transfuse platelets to above 50k for the procedure. I'd minimize FFP — it raises portal pressure and may worsen the variceal bleeding without meaningfully improving hemostasis in this context.

Examiner: You're concerned about portopulmonary hypertension. How do you evaluate for it?

Me: Portopulmonary hypertension is a contraindication to liver transplantation if the mean PAP is above 50 mmHg, and carries high surgical risk above 35 mmHg. I'd place a pulmonary artery catheter — Swan-Ganz — to get direct PAP measurements. If the mean PAP is above 35, I'd push back on urgent TIPS and communicate the risk clearly. I'd avoid anything that increases PVR: hypoxia, hypercarbia, pain, hypothermia.

Examiner: During the case, his BP crashes to 60/30 after the TIPS balloon inflates. What do you do?

Me: Portal decompression drops the systemic afterload suddenly — the portal system was acting as a high-resistance reservoir and now it's been opened. I'd push norepinephrine immediately to defend the MAP. I'd have vasopressin available as a second agent. I'd give a fluid bolus, probably 250-500 mL of albumin rather than saline — there's evidence for albumin in cirrhosis. I'd call for help and alert the GI team.

Key Phrases That Score Points

• "RSI first — stomach full of blood, encephalopathic patient, I'm not waiting for labs before securing the airway."
• "TEG or ROTEM guides my blood products in cirrhosis — not the INR alone."
• "Cryoprecipitate and PCC over large volumes of FFP — FFP raises portal pressure."
• "Mean PAP above 35 is high surgical risk for TIPS or liver transplant — I need a Swan."
• "Portal decompression causes sudden BP crash — norepinephrine and vasopressin primed before they inflate."

Why This Case Appears on the Boards

The unstable cirrhotic is a classic board trap because it tests whether you understand the unique hematology of liver disease and can translate that into bedside decisions. TEG-guided resuscitation separates the candidates who memorize protocols from those who understand physiology.