Haematemesis, haemoptysis, or both?

Abstract

In February, 2012, a 57-year-old white man presented to us with a 2-month history of orthopnoea. Recumbency caused cough and dyspnoea culminating in bright red haemoptysis. He had been sleeping in an upright position for the past month. He had a 20-pack-year history of smoking but had not smoked for 15 years. His medical history included obesity, type 2 diabetes mellitus, and cirrhosis due to non-alcoholic steatohepatitis. Over the past 7 years our patient had had several episodes of haematemesis requiring repeated endoscopic variceal ligation. His medications included carvedilol, metformin, and sitagliptin. He was centrally obese (BMI 36 kg/m2) and comfortable without respiratory decompensation. Cardiopulmonary examination was unremarkable; examination of the abdomen showed splenomegaly. Full blood count, synthetic liver function, electrolytes, renal profi le, and arterial blood gases were normal. Liver transaminases were slightly high. Child-Pugh score was 5. Chest radiography, lung function tests, and echo cardiography were unremarkable. Contrast enhanced CT of the abdomen showed a cirrhotic looking liver with abdominal varices extending proximally through the diaphragmatic hiatus into the mediastinum. We saw no evidence of pulmonary or hepatic malignant disease. On bronchoscopy large, dilated submucosal veins were seen, consistent with bronchial varices. A transjugular intra hepatic portosystemic shunt (TIPS) was placed with embolisation of the feeding collateral vein using two 22 mm Amplatzer 4 plugs because of continuing haemoptysis and preserved synthetic liver function. During 12 months of follow up, there has been no further haemoptysis, and orthopnoea has resolved. The TIPS stent diameter has been reduced because of encephalopathy. Obesity and metabolic syndrome are an increasing health problem worldwide. With the rising incidence, liver related morbidity is also on the increase. 75% of Lancet 2013; 381: 346