A 55-year-old man is brought to the emergency department due to an episode of hematemesis. He has a history of alcoholic cirrhosis with ascites for the last 2 years. In the emergency department, he is appropriately treated, and has no new episodes of bleeding. He is admitted to the hospital for observation and further work-up. His upper gastrointestinal endoscopy reveals esophageal varices with stigmata of recent bleeding. Which of the following is the most likely complication that he is at risk of developing during his hospitalization?

Question

A 55-year-old man is brought to the emergency department due to an episode of hematemesis.  He has a history of alcoholic cirrhosis with ascites for the last 2 years.  In the emergency department, he is appropriately treated, and has no new episodes of bleeding.  He is admitted to the hospital for observation and further work-up.  His upper gastrointestinal endoscopy reveals esophageal varices with stigmata of recent bleeding.  Which of the following is the most likely complication that he is at risk of developing during his hospitalization?

Quizplus · Accepted Answer

Explanation: Patients who are admitted to the hospital because of recent variceal bleeding are at an increased risk of developing complications during their hospitalization. The principal complications in these patients that lead to increased mortality are infections, hepatic encephalopathy, and renal failure. The most common complication is development of infection (~50% of patients), which usually occurs as a urinary tract infection, spontaneous bacterial peritonitis, respiratory infection, aspiration pneumonia, or primary bacteremia. A large number of trials have evaluated the efficacy of prophylactic antibiotics in patients with cirrhosis who were hospitalized for variceal bleeding. All these trials have suggested a decreased incidence of infectious complications with the use of prophylactic antibiotics. The currently preferred regimen is intravenous ceftriaxone for 7 days, with a transition to trimethoprim-sulfamethoxazole or an oral fluoroquinolone (norfloxacin, ciprofloxacin) if patients are ready for discharge prior to completion of the intravenous antibiotic course. (Choice B) The development of renal failure in these patients can have multiple etiologies, such as acute tubular necrosis (ischemic or toxic) or precipitation of hepatorenal syndrome; however, this complication is not as common as the development of an infection. (Choices C and D) Congestive heart failure is uncommonly seen in these patients. Disseminated intravascular coagulopathy occurs rarely in patients with acute variceal hemorrhage, and is usually seen in the presence of underlying infections. (Choice E) Hepatorenal syndrome is a complication of cirrhosis and a variceal bleed. Hemolytic uremic syndrome(HUS) is associated with Shiga toxin-producing Escherichia coli(E. coli O157:H7), not with cirrhosis. Educational objective: Bacterial infections can develop in up to 50% of patients who are hospitalized for acute variceal bleeding; therefore, these patients should be treated prophylactically with antibiotics.

A 55-Year-Old Man Is Brought to the Emergency Department Due