How should I manage a patient with haematemesis who is stable but has a history of liver disease?

Management of a stable patient with haematemesis and a history of liver disease:

• Assess the patient’s haemodynamic stability and perform a formal risk assessment using the Blatchford score initially, and the full Rockall score after endoscopy.
• Arrange endoscopy within 24 hours of admission to identify the bleeding source and guide treatment.
• Given the history of liver disease, suspect variceal bleeding; offer terlipressin at presentation to control variceal bleeding and continue for up to 5 days or until haemostasis is achieved.
• Administer prophylactic intravenous antibiotics to reduce the risk of infection and complications associated with variceal bleeding in cirrhosis.
• Use endoscopic variceal band ligation for oesophageal varices or endoscopic injection of N-butyl-2-cyanoacrylate for gastric varices as definitive endoscopic treatments.
• Monitor for re-bleeding; if it occurs and is not controlled by endoscopy, consider transjugular intrahepatic portosystemic shunt (TIPS) or interventional radiology, or urgent surgery if radiology is unavailable.
• Manage coagulopathy and thrombocytopenia according to bleeding status and laboratory results, including platelet transfusion if platelets <50 x 10⁹/L and active bleeding, and fresh frozen plasma if INR >1.5 with active bleeding.
• Stop other non-steroidal anti-inflammatory drugs during the acute phase.
• After haemostasis, continue secondary prevention with non-selective beta-blockers (carvedilol or propranolol) or repeat band ligation for medium or large varices, considering patient tolerance and adherence.
• Ensure specialist hepatology referral for ongoing management of liver disease and variceal surveillance.

This approach balances acute management of bleeding with the underlying liver disease context to reduce morbidity and mortality.

References: ¹,²,³