A 57-year-old woman comes to the emergency department due to black stools and 2 episodes of hematemesis over the last 24 hours. Her other medical problems include hypertension, type 2 diabetes mellitus, hypercholesterolemia, and migraine headaches. Current medications include metformin, glyburide, simvastatin, ramipril, and low-dose aspirin. The patient has also been taking naproxen for frequent headaches over the last week. She has smoked a pack of cigarettes per day for 20 years and drinks 1 or 2 cans of beer daily.
Temperature is 36.7 C (98.1 F), blood pressure is 122/70 mm Hg, pulse is 96/min, and respirations are 16/min. Examination reveals a soft abdomen that is mildly tender over the epigastrium. There is no rebound tenderness or rigidity.
Laboratory results are as follows:
After initial fluid resuscitation, the patient undergoes upper gastrointestinal endoscopy in the emergency department; it reveals a 1.5-cm ulcer in the gastric antrum. There is no active bleeding and the ulcer is covered with an adherent clot. Endoscopic hemostatic therapy is performed.
Which of the following is the most appropriate course of action for this patient?

Question

A 57-year-old woman comes to the emergency department due to black stools and 2 episodes of hematemesis over the last 24 hours.  Her other medical problems include hypertension, type 2 diabetes mellitus, hypercholesterolemia, and migraine headaches.  Current medications include metformin, glyburide, simvastatin, ramipril, and low-dose aspirin.  The patient has also been taking naproxen for frequent headaches over the last week.  She has smoked a pack of cigarettes per day for 20 years and drinks 1 or 2 cans of beer daily.
Temperature is 36.7 C (98.1 F), blood pressure is 122/70 mm Hg, pulse is 96/min, and respirations are 16/min.  Examination reveals a soft abdomen that is mildly tender over the epigastrium.  There is no rebound tenderness or rigidity.
Laboratory results are as follows:
 After initial fluid resuscitation, the patient undergoes upper gastrointestinal endoscopy in the emergency department; it reveals a 1.5-cm ulcer in the gastric antrum.  There is no active bleeding and the ulcer is covered with an adherent clot.  Endoscopic hemostatic therapy is performed.
Which of the following is the most appropriate course of action for this patient?

Quizplus · Accepted Answer

11ec193a_9608_59e4_853d_df76c62311c7_MD0002_00 Initial management of upper gastrointestinal (GI) bleeding includes fluid resuscitation, high-dose intravenous proton pump inhibitor (PPI) therapy, and urgent endoscopy (within 24 hours of presentation). Peptic ulcers are the most common cause of upper GI bleeding and are usually due to Helicobacter pylori infection or nonsteroidal anti-inflammatory drugs (NSAIDs). Ulcers with high-risk features for rebleeding (eg, active bleeding, adherent clot, visible vessel) typically require endoscopic treatment. Most rebleeding occurs in the first 72 hours, so patients should be monitored during this time while on high-dose intravenous PPI therapy. A clear liquid diet is advised as urgent interventions (eg, repeat endoscopy) may be needed if bleeding recurs. Stable patients may then be transitioned to a regular diet and oral PPI therapy and discharged. Routine "second-look" endoscopy has not been shown to be beneficial and is indicated only if there is rebleeding, poor visualization during the initial endoscopy (eg, due to blood/debris), or concern that initial endoscopic therapy was suboptimal. (Choices A and B) All NSAIDs should be discontinued in patients with acute GI bleeding. Those who have low-risk ulcers and who are otherwise healthy may receive a regular diet and be discharged on oral PPI therapy after endoscopy. Intermediate-risk ulcers warrant a brief hospitalization. However, this patient is at high risk for rebleeding. (Choice C) Patients who are hemodynamically unstable and/or actively bleeding should be admitted to the intensive care unit. Octreotide is not recommended for routine use in patients with acute nonvariceal bleeding except in unstable patients awaiting definitive endoscopic treatment or when endoscopy is contraindicated/not available. (Choice E) Blood transfusions are recommended for hemoglobin <7 g/dL (or <8 g/dL for patients with comorbid cardiovascular disease). Higher transfusion thresholds should be used for massively hemorrhaging patients or those in shock. This patient's hemoglobin is above the threshold for transfusion, and she is not actively bleeding. Educational objective: Patients with peptic ulcers and high-risk features on endoscopy (eg, active bleeding, visible vessels, adherent clot) typically require endoscopic therapy. Following endoscopy, they should be kept in the hospital, placed on a clear liquid diet for 2 days, and continued on a high-dose intravenous proton pump inhibitor for 3 days to minimize bleeding risks. __________ References: Management of patients with ulcer bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/22310222)

A 57-Year-Old Woman Comes to the Emergency Department Due to Black