📋 Case Analysis: Aliza, 75-Year-Old Female

👤 Patient Demographics

🔴 Chief Complaint

📜 Significant Medical History

1. Hepatitis C → Liver Disease (Cirrhosis) — 25 years

• Patient has had Hepatitis C virus (HCV) infection for 25 years
• Of patients exposed to HCV: ~80% develop chronic hepatitis C; of those, ~20–30% develop cirrhosis over 20–30 years — Harrison's Principles of Internal Medicine 22E
• After 25 years, she is almost certainly in established cirrhosis with portal hypertension
• Key complication: Esophageal varices — present in ~40–60% of cirrhotic patients
• The "projectile vomiting from the esophagus" is a classic description of variceal hemorrhage or upper GI bleed from esophageal varices

2. Diabetes Mellitus — 23 years

• On sugar tablets (likely oral hypoglycemics — "Subarbetal" may be Sitagliptin/metformin)
• Diabetic for 23 years → risk of diabetic nephropathy, neuropathy, retinopathy
• Diabetes + HCV cirrhosis: worse prognosis — HCV itself promotes insulin resistance

3. Vitiligo

• Autoimmune depigmentation disorder
• No breathing problems noted
• HCV has an association with autoimmune conditions including vitiligo — consistent with chronic viral infection

4. Cataracts (Eyes)

• Surgery 4 years ago — currently doing well
• Common in elderly diabetics (diabetic cataracts)

5. BP: 115/70–80 (top normal)

• No active hypertension
• In cirrhosis, BP can be low-normal due to splanchnic vasodilation

6. Sleep: Normal

🦷 Recent Dental Treatment (2–3 months ago)

• Important for infective endocarditis risk assessment (especially if any cardiac valve disease)
• Also relevant for drug-drug interactions and bleeding risk (given likely coagulopathy from cirrhosis)

💊 Medications

• Oral hypoglycemic agent ("Sugar tablets — Subarbetal" = likely Sitagliptin or a sulfonylurea)
• No family history of significant disease
• Vaccinated: Hepatitis (B or A) + COVID-19

🎯 Primary Diagnosis / Problem

Bleeding Esophageal Varices secondary to HCV-Cirrhosis with Portal Hypertension

1. HCV (25 years) → Chronic hepatic inflammation → Progressive portal-based fibrosis → Bridging fibrosis → Macronodular cirrhosis
2. Cirrhosis → Portal hypertension (increased resistance to portal flow)
3. Portal hypertension → Portosystemic collaterals including esophageal varices
4. Varices rupture → Projectile hematemesis (vomiting blood from esophagus)

"Esophageal varices are present in approximately 40% of patients with cirrhosis and in as many as 60% of patients with cirrhosis and ascites... Up to 25% of patients with newly diagnosed varices will experience variceal bleeding within 2 years." — Sleisenger and Fordtran's Gastrointestinal and Liver Disease

⚠️ Risk Stratification

🔬 Investigations Needed

• Endoscopy (EGD) — confirm variceal bleeding, grade varices
• CBC — hemoglobin, platelets (thrombocytopenia in cirrhosis)
• LFTs — bilirubin, albumin, ALT/AST
• PT/INR, aPTT — coagulopathy from liver failure
• Serum creatinine, electrolytes — renal function (hepatorenal syndrome risk)
• HCV RNA quantitative + genotype — disease activity
• Blood glucose, HbA1c — diabetes control
• MELD score (uses bilirubin, INR, creatinine) — predicts 90-day mortality

• Ultrasound abdomen — liver size, echogenicity, splenomegaly, ascites, portal vein Doppler
• Alpha-fetoprotein (AFP) — screen for hepatocellular carcinoma (risk elevated with HCV cirrhosis)
• Child-Pugh score — liver disease severity

💉 Management

Acute Variceal Bleed (if active):

1. IV access + fluid resuscitation (avoid over-transfusion — raises portal pressure)
2. Vasoactive drugs: Terlipressin or Octreotide (reduce portal pressure)
3. Antibiotics: Ceftriaxone (reduces risk of SBP and mortality in cirrhotic bleeders)
4. Urgent endoscopy (within 12 hours): Endoscopic Band Ligation (EBL) — treatment of choice
5. TIPS (Transjugular Intrahepatic Portosystemic Shunt) if bleeding uncontrolled

Secondary Prophylaxis (preventing rebleed):

• Non-selective beta-blockers (Propranolol/Carvedilol) — reduce portal pressure
• Repeat endoscopic band ligation sessions until varices obliterated

Long-term:

• HCV treatment: Direct-Acting Antivirals (DAAs — Sofosbuvir-based regimens) — even in cirrhosis, SVR (cure) slows progression
• Diabetes management: Review oral hypoglycemic — metformin should be used cautiously or avoided in decompensated cirrhosis; prefer insulin or glipizide
• Monitor for hepatocellular carcinoma (6-monthly AFP + ultrasound)
• Liver transplant evaluation if MELD ≥15

🧩 Summary of All Problems (Problem List)