Physician's Assistant

MRN:

Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Haematemesis

History of Presenting Complaint:
Presented with haematemesis starting at approximately 02:30. He reports vomiting fresh red blood and then feeling dizzy to the point that he could not walk. There is no clear history of melaena, although haematemesis was evident and he smelled of melaena on examination. He has had ongoing thirst for the last 72 hours.

He has background decompensated alcohol-related liver disease with ascites, known oesophageal varices and a partial non-occlusive portal vein thrombus. He has had treatment previously to reduce variceal bleeding risk. He also reports discomfort on passing urine and a cough. There has been no current evidence from the history of overt hepatic encephalopathy. He states he has not consumed alcohol for over 2 years, apart from a brief 2-day lapse in the more distant past.

Past Medical History:
• Alcohol-related liver cirrhosis with decompensation and recurrent ascites
• Large ventral hernia, not for surgical management
• Oesophageal varices, grade 2 on two occasions
• Partial longstanding portal vein thrombosis, not anticoagulated
• Drug-induced psychosis with detention under Section 2 Mental Health Act; positive for buprenorphine, THC, benzodiazepines and opiates in September 2025; subsequently commenced on depot antipsychotics
• Hepatitis C (2019)
• COPD (2019)
• Mixed anxiety disorder and post-traumatic stress disorder
• Irritable bowel syndrome
• Upper GI endoscopy (30/12/2025): two grade 2 oesophageal varices and portal hypertensive gastropathy without bleeding
• Multiple recent admissions with recurrent ascites and spontaneous bacterial peritonitis

Drug History:
• Nefopam 60mg PO TDS PRN
• Senna 15mg PO ON
• Furosemide 80mg PO mane and 40mg PO lunchtime
• Mirtazapine 15mg PO ON
• Spironolactone 200mg PO mane and 100mg PO lunchtime
• Co-trimoxazole 80/400mg PO BD
• Propranolol 40mg PO BD
• Omeprazole 40mg PO BD
• Paracetamol 1g PO QDS PRN
• Thiamine 100mg PO OD
• Zuclopenthixol depot injection

Recently Stopped Medications:
• Rifaximin 550mg PO BD - currently held due to concern regarding previous hepatic encephalopathy in the context of TIPS not being pursued

Social History:
Works as a support worker.
Ex-drinker, abstinent for approximately 9 months to over 2 years by history, with only a brief 2-day lapse reported previously.

On Examination:
General appearance: Unkempt. Haematemesis evident around the mouth. No overt hepatic encephalopathy clinically.
Observations:: HR 130, BP 91/62, oxygen saturations normal, respiratory rate normal
• Abdomen: Soft and non-tender. Flank bulging but no abdominal distension apart from a large ventral hernia. Dressing in situ and not currently leaking. Ascites present.
• Cardiovascular: Heart sounds normal.
• Respiratory: Right basal crepitations. Left chest clear.
• Neurological: No asterixis.
• Other: Smells of melaena.

Investigations:
• Urea: 11.6 from baseline 8.5
• Sodium: normal
• Potassium: normal
• ALP: 143, in keeping with baseline
• Bilirubin: 17 from 8
• Amylase: normal
• CRP: 7, previously 4
• AST: 54
• INR: 1.3
• Haemoglobin: 93, from 105 on 17/02/2026
• Venous blood gas: pH 7.47
• Lactate: 6.6
• Recent liver ultrasound: stable appearances of non-occlusive portal vein thrombus
• Chest X-ray: requested due to right basal changes, query aspiration

Impression:
Variceal bleed secondary to decompensated alcohol-related liver disease.
Secondary issues: Ascites, AKI, partial non-occlusive portal vein thrombus, right basal chest changes with possible aspiration, no current evidence of overt hepatic encephalopathy.

Management Plan:
1. Continue terlipressin.
2. Give IV fluid for AKI.
3. Administer human albumin solution.
4. Continue antibiotics.
5. Keep nil by mouth; allow mouth wetting only.
6. Monitor INR and full blood count.
7. Give vitamin K if INR rises above 1.4.
8. Repeat venous blood gas, full blood count and INR at 09:00.
9. If haemoglobin falls, lactate rises, or there is any further haematemesis despite terlipressin, discuss urgently again with the on-call endoscopist.
10. On-call endoscopist has been informed and is content with the current plan, but wishes to be re-contacted if there is further haematemesis or deterioration.
11. Proceed with upper GI endoscopy as indicated, with possible endoscopic treatment of bleeding, possible oesophageal stent placement for tamponade, and possible further intervention to reduce portal pressure if required.
12. Chest X-ray requested to assess right basal changes and possible aspiration.
13. Add ethanol level to blood tests.
14. No clear role for repeat liver ultrasound given the very recent ultrasound showing stable non-occlusive portal vein thrombus.

Summary:

Investigations:

Refined clerking Thu 12 March 2026 21:05

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