ADMITTING DIAGNOSES:
1. Hematemesis.
2. Cirrhosis.
3. Upper gastrointestinal bleed.
HOSPITAL COURSE: The patient is a (XX)-year-old Hispanic male with history of alcohol abuse and alcoholic cirrhosis, who presents to the emergency department complaining of vomiting bright red blood. The patient was seen in consultation by Gastroenterology, and he was found to have both gastric and esophageal varices. The patient continued to have fairly massive upper GI bleeding requiring, throughout his hospital stay, a total of approximately 16 units of packed red cells as well as 10 packs of platelets. The patient had thrombocytopenia as well as significant anemia with hemoglobin dropping under the 5 level. Currently, on discharge, the patient’s hemoglobin is 9.2.
The patient also received IV octreotide throughout his hospital stay. He was also banded by GI. Five esophageal varices were banded. The patient was considered for TIPS procedure, and CT scan of the abdomen was performed. However, unfortunately for this gentleman, a liver mass was found. The patient does have a history of colon cancer, so CEA levels were obtained, and an alfa-fetoprotein level was obtained. The AFP level was markedly elevated, indicating most likely the patient had primary hepatocellular carcinoma due to his underlying cirrhosis. The patient was drinking alcohol until the point of admission to the hospital. Given the fact that the patient had received 16 units of blood, he had been banded and he was not a candidate for TIPS due to his liver tumor, it was felt that the patient would be better served with palliative comfort care measures. The patient’s condition is terminal. His chance of long-term survival is low.
We had a lengthy discussion with the patient and the patient’s wife. All are in agreement that given the patient’s cirrhosis and probable hepatocellular carcinoma with significant esophageal and gastric varices, that the patient would be placed under hospice care and comfort care measures would be initiated. The patient was stable for transfer to a skilled nursing facility on the day of discharge. He was switched to all medications by mouth. He was on a proton pump inhibitor. He was started on Aldactone and Lasix. He was started on Aldactone 50 mg p.o. b.i.d. He was started on Lasix 20 mg p.o. daily. The Sandostatin was stopped.
At the time of discharge, he was no longer actively bleeding. All were in agreement at the time of discharge that if the patient were to rebleed again, comfort care measures and palliative care measures would be instituted rather than return to the hospital with further endoscopy and further transfusion. The patient was tolerating a regular diet without difficulty.
DISCHARGE DIAGNOSES:
1. End-stage alcoholic cirrhosis.
2. Upper gastrointestinal bleeding, requiring 16 units of packed red cells.
3. Esophageal and gastric varices.
4. Portal hypertension.
5. Thrombocytopenia secondary to splenic sequestration.
6. Ascites.
7. Blood loss anemia.
8. History of alcohol abuse.
9. Liver mass with elevated alfa-fetoprotein, most likely indicating primary hepatocellular carcinoma.
