Intended for healthcare professionals

Endgames Case report

A massive haematemesis

BMJ 2010; 340 doi: (Published 28 January 2010) Cite this as: BMJ 2010;340:b5534
  1. Kathryn L Nash, consultant hepatologist1,
  2. Gideon M Hirschfield, assistant professor of medicine2
  1. 1Southampton University Hospitals NHS Trust, Southampton SO16 6YD
  2. 2Liver Centre, Toronto Western Hospital/Department of Medicine, University of Toronto, Toronto, ON, Canada M5T 2S8
  1. Correspondence to: klnash11{at}

    A 31 year old man was brought by ambulance to the emergency department of his local hospital having vomited several basins full of bright red blood. He had no medical history but admitted to a decade long history of excess alcohol intake, consuming 60-70 units a week. On examination he was pale, sweaty, and restless with a marked tremor. His pulse was 110 beats per minute and blood pressure was 90/50 mm Hg. He was not jaundiced, but his abdomen was distended with shifting dullness in the flanks. The liver could not be palpated, but the spleen was palpable 5 cm below the costal margin.

    Blood results showed haemoglobin 80 g/l, international normalised ratio 1.8, platelets 45×109/l, bilirubin 14 μmol/l, creatinine 77 μmol/l.

    While being assessed he had a further large haematemesis, vomiting more than a litre of fresh blood, and he became drowsy and uncooperative.


    • 1 What is the most likely diagnosis?

    • 2 How should he be managed initially?

    • 3 What can be done to control the bleeding?

    • 4 How could this episode have been prevented?

    • 5 What determines his long term prognosis?


    1 What is the most likely diagnosis?

    Short answer

    Decompensated alcoholic liver disease with portal hypertension leading to haemorrhage from gastro-oesophageal varices.

    Long answer

    The most likely diagnosis is that he has developed cirrhosis as a consequence of long standing alcohol use. In the United Kingdom, alcohol is the main cause of liver disease, and it accounts for more than half of liver related admissions to hospital. The problem is increasing, with hospital admissions for alcohol related liver disease having doubled in the past 10 years.1 The spectrum of alcohol associated liver disease spans steatosis, steatohepatitis, and cirrhosis.2

    Sinusoidal hypertension results from compression of the portal venous channels in the fibrotic liver and leads to the development of portosystemic anastomoses. The anastomosis at …

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