A 54-year-old man is brought to the emergency department after an episode of hematemesis and lightheadedness. He has a history of anemia, intravenous drug use, hepatitis C infection with cirrhosis, and alcohol use. The patient says he has had no alcohol in about 5 days. He takes no medications. His temperature is 36.7 C (98 F), blood pressure is 105/60 mm Hg, pulse is 110/min, and respirations are 16/min. He has scleral icterus. Examination shows blood in the oropharynx. The lungs are clear to auscultation. The abdomen is distended with a fluid wave. Laboratory results are as follows: The patient receives normal saline through 2 large-bore intravenous lines and is started on ceftriaxone. Which of the following is the most appropriate next step in management of this patient?

Question

A 54-year-old man is brought to the emergency department after an episode of hematemesis and lightheadedness.  He has a history of anemia, intravenous drug use, hepatitis C infection with cirrhosis, and alcohol use.  The patient says he has had no alcohol in about 5 days.  He takes no medications.  His temperature is 36.7 C (98 F), blood pressure is 105/60 mm Hg, pulse is 110/min, and respirations are 16/min.  He has scleral icterus.  Examination shows blood in the oropharynx.  The lungs are clear to auscultation.  The abdomen is distended with a fluid wave.  Laboratory results are as follows:  The patient receives normal saline through 2 large-bore intravenous lines and is started on ceftriaxone.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d1a5_49e2_bc81_6f0c9baa9c0b_MD0003_00 This patient with hepatitis C and alcoholic liver disease has an upper gastrointestinal hemorrhage, most likely due to esophageal varices. Initial treatment of suspected variceal bleeding includes volume resuscitation, through 2 to 3 large-bore peripheral intravenous lines. Prophylactic antibiotics (eg, ceftriaxone) should be given to cirrhotic patients with gastrointestinal bleeding to decrease infectious complications, recurrent bleeding, and mortality. Somatostatin analogues (eg, octreotide) inhibit the release of vasodilator hormones, which leads indirectly to splanchnic vasoconstriction and decreased portal flow. Urgent endoscopy (within 12 hours) can diagnose and treat (eg, endoscopic band ligation, sclerotherapy) active bleeding. Patients with uncontrollable bleeding require temporary balloon tamponade (eg, Sengstaken-Blakemore, Minnesota, Linton-Nachlas tubes) as a short-term measure until more definitive therapy, including transjugular intrahepatic portosystemic shunt (TIPS) or shunt surgery (Choice E). Patients without further bleeding after endoscopy can be monitored and receive secondary prophylaxis (beta blocker) with repeat endoscopic band ligation 1-2 weeks later. (Choice A) Recombinant factor VIIa is effective in treating some types of hemophilia. However, current studies have not shown significant benefit for correcting coagulopathy in active variceal bleeding. Fresh frozen plasma is commonly used for correcting coagulopathy of liver disease, but it increases the risk of volume overload and may not adequately correct the coagulopathy. (Choice C) Current guidelines suggest keeping the hemoglobin >9 g/dL in variceal hemorrhage. This patient should have serial blood counts drawn and may require transfusion if the hemoglobin decreases to <9 g/dL. (Choice D) Platelet transfusions are generally reserved for patients with active bleeding and platelet count <50,000/mm³. This patient's platelet count of 72,000/mm³ does not require platelet transfusion at this time. Educational objective: Treatment of actively bleeding esophageal varices involves hemodynamic support, pharmacologic treatment (eg, octreotide), endoscopic therapy, and prophylactic antibiotics. Coagulopathy, anemia, and thrombocytopenia are common complications and may also require correction. References: Variceal and other portal hypertension related bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/24160925)

A 54-Year-Old Man Is Brought to the Emergency Department After