Variceal Bleeding in Cirrhosis with Portal Vein Thrombosis and Coronary Disease
Mr E is a 57-year-old man with alcohol-related cirrhosis (Child–Pugh C, MELD 22), portal vein thrombosis diagnosed 18 months ago, and prior NSTEMI with a drug-eluting stent 2 years ago. He takes apixaban 5 mg twice daily, aspirin 81 mg daily, propranolol 40 mg twice daily, spironolactone and furosemide. He presents with two episodes of haematemesis and melaena. Blood pressure 92/56 mmHg, heart rate 118, temperature 37.9°C, and he is drowsy but oriented. Haemoglobin 72 g/L, platelets 58 × 10⁹/L, INR 2.1, fibrinogen 1.2 g/L, creatinine 1.3 mg/dL, lactate 3.4 mmol/L. Ultrasound shows a nodular liver with splenomegaly and known portal vein thrombosis. He is not actively bleeding at the time of assessment, and there are no signs of peritonitis. Endoscopy is available in theatre but not before 6 hours.
1. Outline your resuscitation and pharmacological management in the first 6 hours, including transfusion thresholds and whether you would reverse apixaban.
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Resuscitate while avoiding the classic harms in cirrhosis.
- Transfusion: use a restrictive threshold, transfuse packed cells for haemoglobin below 70 g/L and target 70–80 g/L. Over-transfusion raises portal pressure and increases rebleeding and mortality.
- Coagulation: INR 2.1 in cirrhosis reflects synthetic failure, not a bleeding tendency; do not give fresh frozen plasma just to correct the number. Give fibrinogen concentrate or cryoprecipitate if fibrinogen is below 1.0–1.5 g/L. Platelets of 58 × 10⁹/L are adequate for endoscopy; transfuse only if below 50 × 10⁹/L or if there is active oozing.
- Apixaban: hold it. For life-threatening bleeding, consider andexanet alfa if available, or 4-factor prothrombin complex concentrate 50 units/kg. Do not give vitamin K expecting to reverse a direct oral anticoagulant.
- Vasoactive drug and antibiotic: octreotide 50 micrograms bolus then 50 micrograms/h (or terlipressin), plus ceftriaxone 1 g daily for up to 7 days.
- Hold propranolol while hypotensive, start a proton pump inhibitor infusion, and avoid large-volume crystalloid that worsens ascites and dilutional anaemia.
2. How would you time endoscopy and manage anticoagulation after haemostasis?
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Endoscopy and anticoagulation are linked decisions.
- Timing: endoscopy within 12 hours of presentation once resuscitation is under way; earlier if he is exsanguinating. Band ligation if oesophageal varices are the source.
- After haemostasis: restart aspirin when bleeding has stopped, usually within 24–72 hours, because his stent is 2 years old and dual antiplatelet therapy is no longer required.
- Restarting apixaban: the portal vein thrombosis and prior coronary disease both argue for resumption, but rebleeding risk argues for delay. A common approach is to restart within 3–7 days after confirmed haemostasis, after multidisciplinary discussion, accepting that Child–Pugh C makes bleeding risk high and that apixaban exposure is increased.
- If there is further bleeding, stop anticoagulation and reconsider the balance; portal vein thrombosis extension is a longer-term risk than exsanguination.
Document the decision and the review date, because these patients are frequently lost between teams. The judgement is to individualise rather than apply a fixed number of days.
3. He develops chest pain with ST depression 24 hours later while still bleeding slowly. What is your approach?
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This is the hardest trade-off in the case: active bleeding plus myocardial ischaemia.
- Do not give fibrinolytic therapy. It is contraindicated with recent gastrointestinal bleeding.
- Assess severity: if bleeding is slow and he is haemodynamically stable, treat the ACS medically with nitrates (cautiously), beta-blockade when pressure allows, and antiplatelet therapy after discussion with cardiology.
- If he is unstable with ongoing ischaemia, proceed to coronary angiography via the radial route with minimal heparin and endoscopic cover; have blood products ready. Reversal of apixaban with prothrombin complex concentrate may be needed to permit heparin.
- Restart aspirin early if PCI is performed; the balance favours preventing stent thrombosis, but the addition of clopidogrel should be discussed with cardiology.
- Involve cardiology, hepatology and critical care together. A unilateral decision either to anticoagulate fully or to withhold all antiplatelet therapy is likely to be wrong.
The defensible answer is a shared decision with defined triggers for escalation, not a fixed protocol.