A 49-year-old woman comes to the emergency department with acute-onset hematemesis. She has vomited blood 3 times over the past 3 hours and feels weak and light-headed. She has a history of alcoholic cirrhosis with grade 1 esophageal varices, depression, and prior opiate abuse that is now in remission. The patient takes sertraline, methadone, a multivitamin, folate, and thiamine daily. She does not use tobacco or illicit drugs but drinks 10 ounces of vodka every night.
Temperature is 37.2 C (99 F), blood pressure is 90/50 mm Hg, pulse is 104/min, and respirations are 20/min. The patient appears anxious and uncomfortable. Her abdomen is distended and a fluid wave is present. There is mild asterixis. Rectal examination reveals guaiac-positive brown stools. Skin examination is notable for multiple telangiectasias and palmar erythema.
Laboratory results are as follows:
Intravenous fluids and octreotide are started, and urgent esophagogastroduodenoscopy is planned.
Which of the following is the best next step in management of this patient?

Question

A 49-year-old woman comes to the emergency department with acute-onset hematemesis.  She has vomited blood 3 times over the past 3 hours and feels weak and light-headed.  She has a history of alcoholic cirrhosis with grade 1 esophageal varices, depression, and prior opiate abuse that is now in remission.  The patient takes sertraline, methadone, a multivitamin, folate, and thiamine daily.  She does not use tobacco or illicit drugs but drinks 10 ounces of vodka every night.
Temperature is 37.2 C (99 F), blood pressure is 90/50 mm Hg, pulse is 104/min, and respirations are 20/min.  The patient appears anxious and uncomfortable.  Her abdomen is distended and a fluid wave is present.  There is mild asterixis.  Rectal examination reveals guaiac-positive brown stools.  Skin examination is notable for multiple telangiectasias and palmar erythema.
Laboratory results are as follows:
 Intravenous fluids and octreotide are started, and urgent esophagogastroduodenoscopy is planned.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_960d_d830_853d_43a055735211_MD0002_00 This patient with a history of cirrhosis, varices, and continued alcohol abuse now has hematemesis, suggesting an acute variceal hemorrhage. The immediate goals in management of acute variceal bleeding include hemodynamic resuscitation, prevention and treatment of complications, and termination of bleeding. This patient received appropriate volume resuscitation and octreotide (to constrict the splanchnic circulation and reduce blood flow to the portal vein) with plans for emergent endoscopy; however, she remains at high risk for infection. Active infection (eg, spontaneous bacterial peritonitis, urinary tract infection) is present at the time of admission in up to 20% of patients with cirrhosis and variceal bleeding, and an additional 50% may develop an acute infection during hospitalization. A short (7-day) course of prophylactic antibiotics decreases the risk of recurrent bleeding and infection, improves mortality, and shortens hospitalization. The preferred agents include norfloxacin, ciprofloxacin, or ceftriaxone. Antibiotics should be initiated prior to endoscopy, if possible, and continued even if cultures are negative. (Choice A) Abdominal ultrasound is not indicated acutely in a patient with cirrhosis who presents with gastrointestinal bleeding. However, all patients with cirrhosis, regardless of etiology, should undergo nonemergent surveillance for hepatocellular carcinoma with ultrasonography every 6 months. (Choice C) Lactulose is used in the management of hepatic encephalopathy but is not indicated for acute variceal bleeding. However, variceal bleeding is a risk factor for hepatic encephalopathy, so the patient should be monitored for this complication. (Choice D) Current guidelines recommend transfusion of packed red blood cells to maintain hemoglobin around 7-8 g/dL in patients with active variceal bleeding. Overtransfusion should be avoided as volume overload can lead to rebleeding episodes due to rebound portal hypertension. (Choice E) Coagulopathy (INR >2) and thrombocytopenia (platelets < 50,000/mm³) can be corrected with transfusion of fresh frozen plasma and platelets, respectively. The patient does not require transfusion at this time. ³ Educational objective: Treatment of patients with active variceal bleeding includes hemodynamic resuscitation, intravenous octreotide, prophylactic antibiotics, and endoscopic therapy. Antibiotics are continued for a total of 7 days even if cultures remain negative. __________ References: Antibiotic prophylaxis in variceal hemorrhage: timing, effectiveness and Clostridium difficile rates. (http://www.ncbi.nlm.nih.gov/pubmed/21072894) Variceal bleeding in portal hypertension: bacterial infection and comparison of efficacy of intravenous and per-oral application of antibiotics-a randomized trial. (http://www.ncbi.nlm.nih.gov/pubmed/16148557)

A 49-Year-Old Woman Comes to the Emergency Department with Acute-Onset