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Variceal Haemorrhage — FRCA Final MCQ

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HardIntensive Care MedicineVariceal HaemorrhageFRCA Final

A 56-year-old man (ASA IV) with decompensated cirrhosis (Child–Pugh C, MELD 28) is admitted to intensive care with acute oesophageal variceal haemorrhage. Following tracheal intubation, vasoactive therapy, endoscopic haemostasis and initial resuscitation, he is haemodynamically stable with no evidence of ongoing major haemorrhage. He has no acute coronary syndrome or known ischaemic heart disease. His INR is 2.8, platelet count 45 × 10⁹/L and fibrinogen 1.1 g/L. Which haemoglobin range should be targeted during ongoing red-cell transfusion management?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: E — 70–80 g/L

Explanation lettering: C = shown as A · A = shown as B · E = shown as C · B = shown as D · D = shown as E

D is correct: the appropriate haemoglobin target is 70–80 g/L. Current UK BSG/BASL guidance recommends this restrictive target for haemodynamically stable patients with upper gastrointestinal bleeding. Liberal red-cell transfusion can increase circulating volume and portal pressure, potentially impairing variceal haemostasis and increasing rebleeding. The abnormal INR, platelet count and fibrinogen require separate assessment but do not justify a higher haemoglobin target. Targets of 80–110 g/L are unnecessarily liberal in the absence of ongoing major haemorrhage, acute coronary syndrome or another specific indication. A target of 60–70 g/L risks inadequate oxygen-carrying capacity. During exsanguinating haemorrhage, transfusion should instead be guided by blood loss, haemodynamic compromise and the major-haemorrhage protocol because the measured haemoglobin may initially be misleading.

Reference: McPherson S et al. Decompensated cirrhosis: an update of the BSG/BASL admission care bundle, gastrointestinal bleeding section. Frontline Gastroenterology. 2025. https://fg.bmj.com/content/16/e1/e3