A 44 yr old male a k/c/o CLD Portal HTN Decompensation Grade 4 Esophageal Varices, Portal Gastropathy, T2DM (Controlled), Syst HTN and Pulmonary Koch's on ATT since 2 months presented with Severe Gemetemesis since 12 hrs....He was immediately rushed to OT and Endoscopic Variceal ligation and banding was done....Discuss about the further approach to this patient as Malaena is still continuing and pt is no Razo infusion

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Probably an EVL induced bleeding ulcer Suggest: BT CT PT Ct.PPI Inj.Tranexamic acid 500mgs IV/TDS Inj.Octreotide UGI scopy and can consider gluing the ulcer with cyanoacrylate if significant bleeding Hb is on the Lower side,PCV transfusion Adequate hydration Keep a watch on platelets and transfuse platelets only if they fall below 50,000

Thnkyou doctor But there is no such guidelines in a patient of CLD having Hypersplenism....platelets can go very down

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I agree with your management. Also see his coagulation profile. Accordingly transfuse FFP+/- SDP, make sure he doesn't slip into HE(common after massive UGI bleed) Packed cells transfusion if Hb%<8, Stabilise him, Evaluate for early liver transplantation(this is THE only curative option in decompensated cirrhosis) TIPSS for buying time before transplant, if medical management fails to stop variceal bleed.

Mostly collected blood coming out in form of melena. Terlipressin to be continued for 72h. Antibiotics. If hb drops do relook scopy for slipped band or evl ulcer or another source like gastric varices or pud. First line Att may be stopped and start liver friendly att.

After the ligation Malena can still be there for a week due to prior bleed, till then manage him conservatively with BTs. Check coagulation profile also.If the pt is stable it means bleed has stopped, if not try intra gastric norADR drip.

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Stop ATT for time being; Inj vit K one amp stat: Tab propranolol for gastropathy and bleeding per rectum. Hemogram monitoring & treat as impending Hepatic failure

Melena can persists for 3-4 days. Give somatostatin / octreotide infusion x 48 hours. Repeat ugi to look for missed fundal varices or recent bleed..

Post EVL terlipressin infusion may be of help. Keep pt NPM now. Repeat EVL should be considered after few days. TIPSS may be considered later on.

Melena can persists for 3 -4 days. Give somatostatin / octreotide infusion for 48-72 hours Repeat ugi to look for fundal varices, active

CLD patients with hematemesis ,mostly 90% from Varices...so it is mandatory to band the Varices if it is there...Even after EVL melena can be there upto 5 days... Important thing is if patient is still bleeding there is need for rebook scopy and specially see fo4 fundal varices . Transfuse blood upto Hb more than 7 gm...Correct coagulopathy if INR more than 1.8, Platelet lees than 20000 and fibrinogen less than 100....8f his Koch's is proven then continue ATT as such...

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