Lesson of the week: Epistaxis: an overlooked cause of massive haematemesis in cirrhosis

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Abstract
Case reports Case 1 A 45 year old woman with alcohol induced cirrhosis (Child's-Pugh class C) and idiopathic thrombocytopenic purpura presented with shock after fresh haematemesis. On admission she had a haemoglobin concentration of 24 g/l, platelets 10 × 109/l, and prothrombin time 16.0 s (control 10.0 s). She was resuscitated with transfusion of whole blood, fresh frozen plasma, and platelets. Variceal bleeding was suspected, and she was given an infusion of octreotide. Gastroscopy showed a large volume of fresh blood restricting the view of the oesophagus and stomach. No source of bleeding was identified. The patient's history indicated that variceal bleeding was the most likely cause of blood loss, and a Sengstaken-Blakemore tube was inserted. Blood loss continued for several hours, and the patient remained haemodynamically unstable. Repeated suction of the oral cavity was necessary, prompting examination of the nasopharynx, which showed an arterial bleeding point in the left nasal cavity. Bilateral nasal packs were inserted to achieve haemostasis. The patient's condition deteriorated as a consequence of aspiration pneumonia and renal failure, and she died. Case 2 A 51 year old man with alcohol induced cirrhosis (Child's-Pugh class B) presented with large volume haematemesis. On admission the patient had a haemoglobin concentration of 88 g/l, platelets 116 × 109/l, and prothrombin time 15.6 s. He was resuscitated with transfusion of whole blood and fresh frozen plasma. Gastroscopy within six hours of admission showed medium sized oesophageal varices, with fresh blood along the full length of the oesophagus, which was aspirated. Variceal band ligation was undertaken, as no other source of blood loss had been identified. When the endoscope was withdrawn, fresh blood was seen in the oropharynx, and temporary nasal packs were inserted. Formal examination by an ear, nose, and throat specialist confirmed an active bleeding point in the right posterior nasal cavity, and fresh packs were placed. These were removed after 72 hours, and bleeding did not recur. Alcohol withdrawal symptoms and a left basal pneumonia complicated his recovery. He was discharged home after seven days and had subsequent follow up with an ear, nose, and throat specialist for further treatment of the nasopharyngeal bleeding point.