Cirrhosis has many possible manifestations. These signs and symptoms may be either the direct results of liver cell failure or secondary to the resultant portal hypertension. Portal hypertension can decrease the number of platelets, which increases the risk of bleeding. Additionally, the liver plays a central role in hemostasis, because it is the site of clotting factors synthesis, coagulation inhibitors, and fibrinolytic proteins. Low platelet count and prolonged clotting times may increase the risk of epistaxis arising from minimal trauma, which can cause sometimes serious and occasionally fatal results. We experienced an intraoperative refractory epistaxis in a 60-year-old man with end-stage liver disease (ESLD) due to hepatitis B virus-related hepatocellular carcinoma during liver transplantation. The patient started severe epistaxis after we attempted to place a nasogastric (NG) tube. We describe successful management of massive epistaxis in an operating room under appropriate anesthesia and close hemodynamic monitoring.
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