BIOMOLECULAR AND HEALTH SCIENCE JOURNAL 2018 APRI, 01 (01) 58

CASE REPORT

Hematemesis on Hepatic Cirrhosis Patients in Area

with Limited Facilities

Yudha Klahan1*, Firas Farisi Alkaff2

1
Rumah Sakit Umum Daerah dr. M.M. Dunda Limboto, Gorontalo, Indonesia
2
Fakultas Kedokteran Universitas Airlangga, Surabaya, Indonesia

ARTICLE INFO ABSTRACT

Article history:
Received 2 May 2018 Esophageal variceal haemorrhage is one of the more dangerous complications of hepatic
Received in revised form 25 May cirrhosis. Initial treatment can determine patient mortality and morbidity. But not all
2018 hospitals have adequate facilities and medicines to handle it. The 53-year-old woman came
with a diagnosis of ascites and hematemesis. At the initial examination found hypotension.
Accepted 29 May 2018
Laboratory results show anemia, thrombocytopenia, and leukocytosis. The next morning
the patient's condition worsened and was transferred to ICU. During the ICU patients
receive 10 lpm oxygen support, cefobactam, pantoprazole, PRC transfusion, and dopamine.
Keywords: Patients begin conscious on the 5th day of treatment. Then the patient started getting
Hematemesis diuretics on day 6 and propranolol on day 9. On day 13 the patient's condition improved
Esophageal varices and the patient was discharged for outpatient treatment. Limitations of the endoscopic tool
Hepatic Cirrhosis cause not every hospital in Indonesia can perform emergency endoscopy for therapy.
However, with rapid and appropriate pharmacological therapy, patients can be helped not
to fall into mortality and prevent recurrent bleeding.

© 2018 Biomolecular and Health Science Journal. All rights reserved

.
Introduction risk of esophageal variceal haemorrhage than patients
with milder liver disease (Child-Pugh A and B)(4).
Esophageal variceal haemorrhage is one of the Approximately 30% or 1/3 of patients with
more dangerous complications of hepatic cirrhosis. In esophageal varices will experience bleeding within 1
hepatic cirrhosis, hepatic architecture changes due to year after diagnosis (5). Mortality within six weeks of
liver cell necrosis become regenerative nodules (1). This bleeding is about 15-20%, ranging from 0% in patients
change causes increased blood flow and resistance in the with grade A children to about 30% of patients with
portal vein. Portal hypertension leads to dilatation of grade C (2). If not in therapy, esophageal varices
blood vessels especially those from the azygos vein, mortality is 20-60%, but if therapy was done then the
which then causes varicose veins in the gastrointestinal mortality decreased to 20% (4).
tract (2). The initial treatment of bleeding in the
Esophageal varices are closely related to the gastrointestinal tract can determine the patient's mortality
severity of hepatic cirrhosis. Approximately 30% of and morbidity, so it should be handled rapidly and
newly diagnosed patients with hepatitis cirrhosis already appropriately. Not all hospitals have adequate facilities
have varicose veins and increase to 90% after 10 years and medicines to deal with, therefore we want to share
(3). Severe liver disease (Child-Pugh C) has a greater case reports of severe hematemesis handling in limited
facilities.

* Corresponding author : klahanxix@gmail.com

© 2018 Biomolecular and Health Science Journal. All rights reserved.

e-ISSN: 2620-8636. Available at https://e-journal.unair.ac.id/BHSJ
 BIOMOLECULAR AND HEALTH SCIENCE JOURNAL 2018 APRI, 01 (01) 59

Cases Illustration Treatment on the day 5, the patient was conscious

GCS E4M6V5 and blood pressure 110/60, dopamine
Fifty three years old woman referral from titration began to be lowered. Day-6 the patient's blood
Puskesmas (Pusat Kesehatan Masyarakat/Community pressure was stable 120/80 still with dopamine, then the
Health Center) Buladu came to RS M.M. Dunda District patient was given furosemid 1-1-0, and spironolacton 1 x
Gorontalo, with diagnosis of ascites and hematemesis. 25mg. The 8th day of antibiotic and chromed
Swelling of the entire body was felt long ago, first administration was discontinued, the dose of furosemide
swelling felt in the legs and stomach. The stomach felt was raised to 2-1-0. Day 9 the patient given propanolol 3
bigger and tense but did not make breathless. Patients x 10mg. Day-13 patient condition stabilized compos
feel nausea and decreased appetite, heat loss, and mentis consciousness, blood pressure 110/60, pulse 75x /
dizziness since 5 days ago. Vomiting and black min, breath 24x / minute, and temperature 36oC.
defecation since 2 days ago, vomiting> 5x daily volume Laboratory examination showed improvement in
of approximately 1 glass of water glass package (around hemoglobin, leukocyte, and platelet counts (table 1). The
250 ml). The patient felt lethargic, unable to stand and patient was then discharged for outpatient care.
consciousness begins to apathetic. History of diabetes
mellitus and hypertension was refuted, history of taking
painkillers was denied. Discussion
Based on the initial physical examination of the
clock obtained GCS E4M6V5, compos mentis, The first step in treating upper GI bleeding is to
hypotension 90/60, normal pulse 88 x/ m. Conjuctiva identify the source of bleeding, whether variceal or non-
anemic, larged abdomen with undulation tests and variceal. Variceal hemorrhage is generally followed by
shifting dullness positive, rough ronkhi in both basal signs of hepatic failure and portal vein hypertension such
lung, and anasarka edema. Laboratory tests obtained as ascites, gynecomastia, spider nevi, palmar erythema
very low hemoglobin, accompanied by leukocytosis and (6). Then evaluate the degree of patient bleeding, plug
thrombocytopenia (Table 1). Patients were diagnosed double IV line, prepare ICU space, intubation, and
with hematemesis and melena et causa esophageal access the central vein (CVC). Perform fluid
varices of dd gastritis erosiva and acute kidney failure. resuscitation with blood pressure target> 80mmHg and
Initial therapy was given infusion of 0.9% NaCl ruwatan, transfusion with target Hb> 8g/dl (7).
chrome, tranexamic acid, omeprazole, and sucralfat Strict supervision due to too much fluid/transfusion in
syrup. patients with variceal hemorrhage may aggravate
bleeding due to intravascular volume increase, and result
Table 1. Result of Laboratorium Examination in complications of pulmonary edema and ascites after
Parameter 07-Feb 11-Feb 15-Feb 20-Feb hemostasis is reached (8). This patient was initially given
only ruwatan liquids because the blood pressure target
Hb 2,5 4,3 6,5 9,2 was reached 90/60, but the inborn Hb was very anemic
Leu 21,6 10,7 6,42 8,85 2.5 and the maximum cito blood was only 2 bag/day.
Give splanic vasoconstrictor therapy such as
Tro 20 97 85 88
terlipressin or somatostatin. Ditipresin modifies the
Hct 9,60% 12,3% 17% 28,70% hemodynamic system by decreasing cardiac output and
Ery 1,24 1,73 2 3,41 increasing arterial blood pressure and systemic vascular
resistance. When suspected variceal bleeding, patient
was given a dose of 2 mg/h for the first 48 hours and
The patient's condition then worsens, the morning continued for up to 5 days then the dose was decreased 1
GCS decreases E1M3V1 and blood pressure 100/50. mg/h or 12-24 h after bleeding stopped (4). Somatostatin
Once NGT installed black blood obtained as much as was given 250 dose loading dose and then continued
750 cc. Patients mounted non-rebreathing mask 10 lpm, with dextrose dextrose 5% 250 μg/h (6 mg/day) (8).
cefobactam antibiotic 2 x 1gr, omeprazole replaced with Antibiotic prophylaxis was given to treat infections such
pantoprazole, patient was recommend to fasting, PRC as spontaneous bacterial peritonitis. Selected antibiotics
transfusion, dopamine syringe pump, and patients treated of ceftriaxone or quinolone may be administered orally
in ICU. or IV, for 7 days (7). In this patient due to limited
Examination of thorax photograph obtained by available drugs, there was no vassopressin drug, while
cardiomegaly accompanied by sign of pulmonary dam antibiotics are given cefobactam 2 x 1gr.
and minimal effusion of sinus pleura. Abdominal Endoscopic therapy is the primary choice in the
ultrasound acquired hepatic cirrhosis with massive treatment of variceal bleeding, and should be done in less
ascites with splenomegaly is considered hypertensive than 12 hours after bleeding. Visual endoscopy can
portal (Fig. 1). differentiate the location of varicose veins, whether in
 BIOMOLECULAR AND HEALTH SCIENCE JOURNAL 2018 APRI, 01 (01) 60

the esophagus or gastric, the choice of therapy may be by endoscopic examination which is the standard standard
ligation or sclerotherapy (7) (figure 2). In this case, the for diagnosis, assessing possible varicose veins and
hospital actually has an endoscope but only as a management based on the underlying disease.
diagnostic tool, so that the patient is considered The limitations of expensive endoscopic devices and
endoscopic after a stable vital condition. rare operator personnel make not every hospital in
Indonesia can perform emergency endoscopes. However,
Table 2. Comparison of mortality risk and re-bleeding with rapid and appropriate pharmacological therapy, it
with combination therapy (9) can help patients not to fall into mortality and prevent
recurrent bleeding.
Management Rebleeding report Mortality report
No 55-67% 23-64% Conflict of Interest
management
Inhibitor ß 37-57% 13-39% The author stated there is no conflict of interest
EIS 34-53% 18-36%
EIS + inhibitor 19-49% 7-26%
ß References
EBL 20-43% 19-34%
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ISMN Simadibrata M, Setiati S, editors. Buku Ajar Ilmu Penyakit Dalam.
12-22% 18-35% 4 ed. Jakarta: Pusat Penerbitan Departemen Ilmu Penyakit Dalam
TIPS
Fakultas Kedokteran Universitas Indonesia; 2006. p. 443-6.
DSRS 11-31% 22-55% 2. Garcia-Tsao G, Bosch J. Varices and Variceal Hemorrhage in
Cirrhosis: A New View of an Old Problem. Clinical
gastroenterology and hepatology : the official clinical practice
EIS=endoscopic injection sclerotherapy, EBL=endoscopic journal of the American Gastroenterological Association.
band ligation, ISMN=isosorbide-5-mononitrate, 2015;13(12):2109-17.
TIPS=transjugular intrahepatic portal-systemic shunt, 3. World Gastroenterology Organisation. World Gastroenterology
DSRS=distal splenorenal shunt. Organisation Global Guidelines: Esophageal Varices. Milwaukee:
World Gastroenterology Organisation; 2014. p. 1-14.
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Once the severity is resolved and the blood pressure 2010;3(2):15 pages.
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Facta Universitatis. 2006;12(3):164-7.
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splanic vasoconstrictors (9). The combination of Sugihartono T, et al. Faktor Risiko Terkait Perdarahan Varises
propanolol and ISMN may decrease the incidence of Esofagus Berulang Pada Penderita Sirosis Hati. Jurnal Penyakit
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7. Bendtsen F, Krag A, Moller S. Treatment of acute variceal
sclerotherapy and propanolol is likely to be 30-42% (9, bleeding. Digestive and liver disease : official journal of the Italian
10) (table 2). Society of Gastroenterology and the Italian Association for the
Choice of nonselective β-adrenergic drug may be Study of the Liver. 2008;40(5):328-36.
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obliteration after 2-4 sessions, then the first surveillance
done 1-3 months after obliteration then every 6-12
months. ISMN is given at an initial dose of 10 mg per
oral per night, increased to a maximum dose of 2 x 20mg
daily or blood pressure> 95mmHg (10)

Summary

Esophageal varices are dilated submucous portion of

veins into the esophagus, occurring in patients with
portal hypertension and may cause serious upper GI
bleeding. All patients with variceal bleeding require