A 55-year-old male patient with a history of more than 30 years of alcohol consumption, averaging about 100-150ml per day, was presented. Six years ago, he was diagnosed with alcoholic liver disease due to liver dysfunction and received symptomatic treatment including abstinence and liver protection at our hospital. Subsequently, he has been regularly followed up at the Digestive and Liver Disease Department. Three years ago, he was admitted to our hospital due to hematemesis. Gastroscopy revealed ruptured and bleeding esophageal varices. After undergoing EVL for hemostasis and receiving comprehensive internal medicine treatment, he showed improvement and was discharged. Post-discharge, he was prescribed oral propranolol (10mg twice a day) to reduce portal vein pressure. On January 26, 2023, the patient experienced recurrent hematemesis after consuming solid food, leading to his emergency admission to our hospital. Routine and biochemical examinations revealed the following: WBC: 4.67X10^9/L, RBC: 3.28X10^12/L, HGB: 88g/L, PLT: 26X10^9/L, AST: 104U/L, ALT: 31U/L, DBIL: 24.2umol/L, TBIL: 43.1umol/L, PT: 16.6sec, ALB: 25.1g/L, APTT: 34.5sec, PTA: 46.6%, INR: 1.46, and FIB: 1.020g/L. Computerized tomography revealed liver cirrhosis, splenomegaly, a small amount of ascites in the abdominal cavity, and esophageal varices. Emergency gastroscopy confirmed the presence of ruptured and bleeding esophageal varices, leading to the clinical diagnosis of alcoholic liver cirrhosis with decompensated esophageal variceal rupture (Child-Pugh B). With consent obtained from the patient and his family members, emergency endoscopic esophageal variceal ligation was performed (refer to Figure I for the specific procedure). Post-surgery, the patient underwent fasting, received somatostatin to reduce portal vein pressure, underwent cefoperazone sodium treatment for anti-infection, received a 400ml transfusion of suspended red blood cells to correct anemia, and was provided compound amino acids (3AA) with various vitamins for symptomatic nutritional treatment following improvement.

On the third day following the surgery (January 30, 2023), the patient exhibited yellowing of the skin and sclera. The results of blood tests, liver function, and coagulation function showed deterioration. The findings were as follows: WBC: 5.73X10^9/L; RBC: 2.79X10^12/L; HGB: 76g/L; PLT: 36X10^9/L; AST: 222U/L; ALT: 69U/L; DBIL: 219umol/L; TBIL: 309umol/L; PT: 23.5sec; APTT: 49.9sec; PTA: 29.3%; INR: 2.10; FIB: 1.52g/L. The clinical diagnosis was acute-on-chronic liver failure (type B). The patient was advised to observe bed rest and received magnesium isoglycyrrhizinate injections for liver protection, Transmetil (Ademetionine 1,4-Butanedisulfonaate) injections to manage jaundice, a 300ml infusion of fresh frozen plasma, and a 400ml intravenous drip of suspended red blood cells to improve coagulation function and address anemia. Two days later (February 2, 2023), a re-examination of blood routine and biochemical indicators revealed the following values: WBC: 6.53x10^9/L; RBC: 3.0x10^12/L; HGB: 81g/L; PLT: 49x10^12/L; AST: 48U/L; ALT: 131U/L; DBL: 278.4umol/L; TBL:435u/L; PT: 21sec; APTT: 50.4sec; PTA: 34%; FIB: 2.11g/L. However, bilirubin levels continued to rise, and the patient showed poor response to the comprehensive internal medicine treatment. With the patient’s and family’s consent, DPMAS+PE treatment was administered on February 3, 2022. One day later (February 4, 2023), a blood re-examination showed the following results: WBC: 6.17x10^9/L; RBC: 2.63x10^12/L;HGB:72g/L; PLT:48x10^12/L; AST:79U/L; ALT: 37U/L; DBL:196.3umol/L; TBL :316.0u/L; PT:17.4sec; APTT:41.6sec; PTA:43.7%; FIB:2.040g/L. DPMAS+PE treatment was administered once again on February 6th, 2023. The subsequent blood routine and biochemical indicators, reviewed on February 7th, 2023, showed the following values: WBC: 5.53x10^9/L; RBC: 2.91x10^12/L; HGB: 77g/L; PLT: 53x10^12/L; AST: 88U/L; ALT: 43U/L; DBL: 183.9umol/L; TBL: 279.3u/L; PT: 18.7sec; APTT: 40.6sec; PTA: 39.7%; FIB: 1.870g/L. The patient’s symptoms of poor appetite and fatigue had significantly improved. On February 9th, 2023, a blood test showed the following results: WBC: 5.99x10^9/L, RBC: 2.93x10^12/L, HGB: 77g/L, PLT: 55x10^12/L, AST: 99U/L, ALT: 58U/L, DBL: 193.5umol/L, TBL: 284.2u/L, PT: 19.3sec, APTT: 42.2sec, PTA: 38.1%, FIB: 1.620g/L. The patient continued to receive basic treatment such as liver protection and jaundice relief. Additionally, due to the presence of anemia, another transfusion of suspended red blood cells (400ml) was administered to address the anemia. On February 12th, 2023, a blood test showed the following results: WBC: 8.36x10^9/L, RBC: 3.23x10^12/L, HGB: 83g/L, PLT: 47x10^12/L, AST: 95U/L, ALT: 81U/L, DBL: 185.2umol/L, TBL: 267.6u/L, PT: 20.1sec, APTT: 45.1sec, PTA: 36.1%, FIB:1.270g/L. Considering the patient’s persisting symptoms of fatigue and poor appetite, as well as the prolonged elevation of bilirubin levels, DPMAS+PE treatment was administered again on February 13th, 2023. Two days later (February 15th), a review of blood routine and biochemical indicators revealed the following values: WBC: 9.05x10^9/L; RBC: 3.22x10^12/L; HGB: 82g/L; PLT: 46x10^12/L; AST: 58U/L; ALT: 55U/L; DBL: 142.3umol/L; TBL: 197.5u/L; PT: 17.2sec; APTT: 38.4sec; PTA: 44.4%; FIB: 1.680g/L. Two days later (February 17th), the blood routine and biochemical indicators were reviewed again, showing the following values: WBC: 5.66x10^9/L; RBC: 3.14x10^12/L; HGB: 80g/L; PLT: 34x10^12/L; AST: 58U/L; ALT: 66U/L; DBL: 112.8umol/L; TBL: 148.1u/L; PT: 18.4sec; APTT: 42.7sec; PTA: 40.6%; FIB: 1.210g /L. The patient’s condition remained relatively stable, and maintenance treatment, including liver protection and jaundice relief, was continued during this period. Another transfusion of suspended red blood cells (400ml) was administered to address the anemia.

Two days later, on February 20th, a follow-up blood routine and biochemical analysis was conducted, revealing the following results: WBC: 5.95x10^9/L; RBC: 3.87x10^12/L; HGB: 96g/L; PLT: 34x10^12/L; AST: 88U/L; ALT: 96U/L; DBL: 114.6umol/L; TBL: 159.2u/L; PT: 17.1sec; APTT: 36.7sec; PTA: 44.7%; FIB: 1.640g/L. With the patient’s condition being stable, the patient and their family requested discharge due to the high medical expenses. They were informed that the patient should have a follow-up outpatient visit at the hospital where the author is located after discharge. Subsequent telephone follow-ups conducted after March indicated that the patient’s general condition was good, and they were able to engage in light physical activity.