The bleeding dilemma #(the maze of upper GI bleeding#)

A 45-year-old man presented with a massive attack of upper GI bleeding was admitted to our hospital. Immediate treatment was done (intravenous fluids, Sandostatin infusion, proton pump infusion, vitamin k intravenous, blood transfusion, and third-generation cephalosporin intravenous). Despite resuscitation, the patient still shocked (the patient looks pale, anxious, and sweaty). Also, the pulse is weak and rapid. The measured blood pressure is 110 systolic and 60 mmHg diastolic (the patient is known hypertensive with blood pressure about 155 over 90 just before the attack of bleeding. The patient gave a history of a previous attack of upper GI bleeding one week ago. Upper GI endoscopy revealed esophageal varices. Band ligation was done with stabilization of the general condition, and the patient was discharged home.
The patient underwent another upper GI endoscopy. The scope was done under general anesthesia, and the endotracheal tube was inserted into the patient's trachea.
The scope revealed a large amount of fresh blood in the stomach and the previously ligated esophageal varices. Some bands are still in place with oozing of blood from around the ligated band, and the others are displaced.
In this case, the operator injects the varices with ethanolamine. After the endoscopy, the patient readmitted to the ICU unit. The patient completed his management and was discharged from the hospital after five days.

Notes

1-There is no visible site of bleeding (maybe from the areas around the ligated bands or from the slipped bands).
2- the fundus of the stomach is not well visualized. However, the endoscopist cannot see any fundal varices.
3- The cause of no active bleeding during the endoscopy may be due to the massive bleeding. In many cases, after fluids and blood resuscitation, the bleeding can recur). So, it is advisable to manage even if there is no active bleeding at the moment.
4- The operator prefers injection of the esophageal varices over band ligation as the ligation apparatus did not give a chance for suction of blood. Also, it impairs the full visualization of the varices. Lastly, the injection of the varices secures the bleeding from all the lengths of the varices. Good injection leads to fibrosis of all the varices, including the sites of bleeding), uniquely when the endoscopist cannot identify the exact source of bleeding.