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Clinical Review Lesson of the week

Epistaxis: an overlooked cause of massive haematemesis in cirrhosis

BMJ 2003; 326 doi: (Published 22 February 2003) Cite this as: BMJ 2003;326:440
  1. Shawinder S Johal, specialist registrar,
  2. Andrew S Austin, specialist registrar,
  3. Stephen D Ryder, consultant gastroenterologist (
  1. Division of Gastroenterology, University Hospital, Queen's Medical Centre, Nottingham NG7 2UH
  1. Correspondence to: S D Ryder
  • Accepted 2 September 2002

Epistaxis should be considered as a cause of massive haematemesis in patients with cirrhosis

The national audit of acute upper gastrointestinal haemorrhage reported an overall incidence of acute upper gastrointestinal haemorrhage in the United Kingdom of 103 cases per 100 000 adults a year. Varices have been identified as the source of blood loss in 8% of patients aged less than 60 years, and mortality among these patients is four times the overall mortality for the age group in patients with haematemesis.1

The most dramatic presentations often occur in patients with chronic liver disease. Variceal bleeding is a life threatening complication of cirrhosis, and survival is closely related to failure to control haemorrhage or early rebleeding, which occurs in as many as 50% of patients.2 In cases of suspected variceal bleeding, immediate treatment with agents such as terlipressin or octreotide is recommended, followed within 12 hours by upper gastrointestinal endoscopy, which is essential for accurate diagnosis and allows variceal sclerotherapy or band ligation.3 Endoscopic diagnosis can be difficult when views are obscured by blood. Nevertheless, a diagnosis of variceal haemorrhage is acceptable when a venous spurt is seen or there is fresh blood in the lower …

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