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Suspected variceal upper gastrointestinal bleeding with haemodynamic instability — MRCEM SBA MCQ

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EasyResuscitation and critical illnessSuspected variceal upper gastrointestinal bleeding with haemodynamic instabilityMRCEM SBA

A 58-year-old man with cirrhosis and previously documented oesophageal varices is brought to the emergency department after vomiting a large volume of fresh blood. He vomits more blood during assessment. His pulse is 132/min and blood pressure is 78/42 mmHg. He is alert and maintaining his airway. Two large-bore intravenous cannulas are in place, and blood products and an emergency endoscopy team are available. His first haemoglobin result is 104 g/L. Which management plan is most appropriate?

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Correct answer: B — Start blood-product resuscitation; give terlipressin and prophylactic antibiotics; arrange endoscopy immediately after resuscitation.

Ongoing large-volume haematemesis with marked hypotension and tachycardia indicates severe bleeding requiring immediate resuscitation; the initial haemoglobin does not override the clinical picture. Cirrhosis and known oesophageal varices make variceal bleeding sufficiently likely to treat at presentation, without waiting for endoscopic confirmation. NICE recommends blood products according to the local massive-bleeding protocol, terlipressin and prophylactic antibiotics for suspected variceal bleeding, and endoscopy immediately after resuscitation in an unstable patient. ([nice.org.uk](https://www.nice.org.uk/guidance/cg141/chapter/Recommendations)) A omits terlipressin and substitutes a proton pump inhibitor, which does not address suspected variceal bleeding. C includes the appropriate initial treatments but uses the endoscopy timing for patients who are not haemodynamically unstable. D delays the indicated first endoscopic assessment for CT angiography; radiological intervention has a different role, including selected cases of re-bleeding after endoscopic treatment. E omits prophylactic antibiotics, which should be given at presentation even when infection is not apparent. The patient needs ongoing senior-led resuscitation and urgent definitive endoscopic care, not observation while awaiting a routine endoscopy slot. ([nice.org.uk](https://www.nice.org.uk/guidance/cg141/chapter/Recommendations))

Reference: NICE CG141: Acute upper gastrointestinal bleeding in over 16s: management — Recommendations (Published 2012; updated 2016) — https://www.nice.org.uk/guidance/cg141/chapter/Recommendations NICE QS38: Prophylactic antibiotic therapy for variceal bleeding (Published 2013) — https://www.nice.org.uk/guidance/QS38/chapter/quality-statement-6-prophylactic-antibiotic-therapy-for-variceal-bleeding