This 56-year-old white male came to the emergency room because of weakness, lack of appetite, shortness of breath, abdominal distention, and an altered mental status. He was a known alcoholic who drank approximately one pint of whiskey per day. Physical examination revealed a wasted appearance, icterus, a protuberant abdomen, bilateral gynecomastia, sparse axillary hair, and spider angiomata on his chest. Liver and spleen were not palpable, the testes were atrophic, and the legs showed petechial hemorrhages and 3+ edema. Admission laboratory values revealed a hemoglobin of 9.5 g/dL, an MCV of 106 fL, a platelet count of 97,000/mL, and a prothrombin time of 19.2 seconds. In addition, his albumin was 2.3 g/dL, bilirubin, total 6.5 mg/dL, AST 21.0 U/L, ALT 56 U/L, alkaline phosphatase 180 U/L, and GGT 320 U/L. The patient was treated with given thiamine, folate, multivitamins, and vitamin K and an intravenous line was placed to infuse 5% dextrose. An esophagogastroduodenoscopy (EGD) was performed which demonstrated large esophageal varices with evidence of previous bleeding sites. Two days after admission the patient developed a massive hematemesis and his hematocrit dropped due to 17%. Emergency EGD showed ruptured rupture of an esophageal varices. Despite and despite successful sclerotherapy and supportive transfusions, the patient lapsed into coma and died the next day.