HEPATOLOGY

Take a focused history from a stable patient presenting with variceal bleeding, to include past medical history, drug and allergy history, social history and family history. Consider asking in more detail about relevant risk factors for chronic liver disease including alcohol, drugs, tattoos and sexual history.

If appropriate, examine the patient and report on any clinical signs of chronic liver disease.

After seeing the patient, consider the following questions:

• What are your top three top differential diagnoses? Give two features of this history that make this more or less likely.
• What initial investigations might be useful and what are you expecting them to show?
• Suggest an initial management plan for the patient.

For the patient you have just seen, review the notes and calculate a Glasgow Blatchford Score.

• What does this score imply for the patient?

Consider the following questions:

• Did this patient require blood transfusion on admission? What is the criteria for urgent blood transfusion?
• What provision is available in your hospital for patients who are experiencing life threatening bleeding?

On the trust intranet, find the major haemorrhage protocol. Answer the following questions:

• How is the major haemorrhage protocol activated?
• When should the major haemorrhage protocol be activated?
• What team members are involved once the major haemorrhage protocol is activated?

Find a blood transfusion request form. Practice completing it with respect to the patient you have seen.

• What is the difference between a 'group and hold' and 'crossmatch' request?

Find a blood transfusion prescription chart. Practice prescribing packed red cell transfusions.

Find the blood products guideline on the trust intranet. Consider:

• What other blood products are available?
• When might they be used?

Practice prescribing some of the blood products you have found.

Consider the following questions:

• When might intensive care input be needed in patients with variceal bleeding?
• How should patients with variceal bleeding be followed up on discharge?
• What is the role of beta-blockers and TIPSS for primary and/or secondary prevention of oesophageal varices?

Further learning opportunities:

• Go and observe an upper GI endoscopy or watch one online. Consider what endoscopic therapies are used to treat oesophageal varices?

Highlight three key things you have learned today. Summarise them on a post-it note and keep it somewhere you will find in a week or two.

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1. Histories: http://www.oscestop.com/Abdomen_histories.pdf
2. ABCDE of UGIB: https://geekymedics.com/acute-management-of-upper-gi-bleeding/
3. General info: Oxford Handbook of Clinical Medicine, Oxford Handbook: The Foundation Programme
4. UK Guidelines on Management of Variceal Haemorrhage: https://gut.bmj.com/content/64/11/1680
5. 2019 review on Management of UGIB: https://www.bmj.com/content/364/bmj.l536
6. NICE guidance Acute UGIB: https://www.nice.org.uk/guidance/cg141/chapter/1-guidance
7. BMJ Best practice: https://bestpractice.bmj.com/topics/en-gb/456/differentials#diffUncommon
8. British society for gastroenterology/British association for study of liver “Liver Bundle within 24 hrs” guideline: https://www.bsg.org.uk/resource/bsg-basl-decompensated-cirrhosis-care-bundle.html