Suspected acute variceal upper gastrointestinal bleeding — MRCEM SBA MCQ

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EasyGastrointestinal and surgical emergenciesSuspected acute variceal upper gastrointestinal bleedingMRCEM SBA

A 56-year-old man with alcohol-related cirrhosis and previous oesophageal variceal banding presents after two episodes of fresh haematemesis. His pulse is 116/min and blood pressure is 102/64 mmHg. Intravenous access, crossmatching and resuscitation are under way, and urgent endoscopy is being arranged. He is afebrile and has not yet received medication for this bleed. Which pharmacological plan is most appropriate now?

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Correct answer: C — Start terlipressin and prophylactic intravenous antibiotics.

Fresh haematemesis in a patient with cirrhosis and a history of variceal banding warrants treatment for suspected variceal bleeding before endoscopic confirmation. NICE recommends terlipressin and prophylactic antibiotics at presentation for suspected variceal bleeding. Its cirrhosis guideline specifies intravenous antibiotic prophylaxis for people with cirrhosis and upper gastrointestinal bleeding. Being afebrile does not remove a prophylactic indication. Resuscitation and arrangements for urgent endoscopy continue in parallel. ([nice.org.uk](https://www.nice.org.uk/guidance/cg141/chapter/Recommendations)) A provides the indicated antibiotics but substitutes a proton pump inhibitor for terlipressin. A proton pump inhibitor would be indicated if endoscopy instead demonstrated non-variceal bleeding with stigmata of recent haemorrhage. B includes terlipressin but omits antibiotic prophylaxis; a proton pump inhibitor does not replace it. D also omits prophylaxis, incorrectly treating the absence of apparent infection as a reason to withhold it. E provides prophylaxis but omits terlipressin while variceal bleeding remains suspected. Neither indicated treatment should wait for the endoscopy result. ([nice.org.uk](https://www.nice.org.uk/guidance/cg141/chapter/Recommendations))

Reference: NICE CG141: Acute upper gastrointestinal bleeding in over 16s: management, recommendations 1.4.4 and 1.5.1–1.5.2 (Published 2012; last updated 2016) — https://www.nice.org.uk/guidance/cg141/chapter/Recommendations NICE NG50: Cirrhosis in over 16s: assessment and management, recommendation 1.3.9 (Published 2016; last updated 2023) — https://www.nice.org.uk/guidance/NG50/chapter/Recommendations