GI Bleed & ESLD: Child-Pugh C
Hematologic mastery in the setting of end-stage liver disease, focused on coagulopathy and portopulmonary hypertension.
"A 45 y.o. male with alcohol-related cirrhosis (Child-Pugh C) presents with acute hematemesis and melena. BP 85/50, HR 120. Hct 21%, INR 2.8, Plts 45k. Surgeon wants urgent EGD or TIPS..."
Resuscitation in ESLD, management of variceal bleeding, and the logic regarding portopulmonary hypertension (pPAP thresholds).
The 'unstable cirrhotic' is a classic board trap. Defenders must prioritize TEG/ROTEM-guided targeted resuscitation over 'shotgunning' blood products.
How a Board-Certified Consultant answers this scenario.
End-stage liver disease (ESLD) with an active GI bleed is a high-risk scenario due to coagulopathy, potential encephalopathy, and high aspiration risk. First, I will perform a Rapid Sequence Induction with cricoid pressure to secure the airway, as the stomach is likely full of blood.
I will manage his coagulopathy by using point-of-care testing (TEG or ROTEM) to provide targeted transfusions—favoring Cryoprecipitate or Prothrombin Complex Concentrate over large volumes of FFP, which can worsen portal hypertension and increase bleeding. My goals are to maintain cerebral perfusion and renal function while avoiding fluid overload. If there is concern for portopulmonary hypertension, I will place a Swan-Ganz catheter to monitor pulmonary artery pressures; I'll defend a MAP of 65 and maintain high vigilance for the cardiovascular collapse that can occur during portal decompression.