A 46-year-old man is brought to the emergency department by the police after being found unresponsive on a nearby park bench. Previously, the patient was brought to the hospital on several occasions due to acute alcohol intoxication. No other history can be obtained. The patient appears disheveled and has a strong smell of alcohol. Temperature is 36.1 C (97 F), blood pressure is 110/76 mm Hg, and pulse is 84/min. Pulse oximetry shows 98% on ambient air. The patient does not follow instructions and withdraws all extremities to painful stimuli. The mucous membranes are dry, and he has several spider angiomata and bilateral gynecomastia. The lungs are clear to auscultation and heart sounds are normal with no murmur. There is moderate abdominal distension with shifting dullness. The liver edge cannot be palpated. While being evaluated in the emergency department, the patient vomits a large amount of bright red blood. Repeat vital signs show that blood pressure is 100/50 mm Hg and pulse is 110/min. Two large-bore peripheral lines are placed and intravenous fluid is administered. The initial appropriate steps are taken for this patient, and an upper gastrointestinal endoscopy is planned. Laboratory results are as follows:
Which of the following is the most appropriate next step in management of this patient?

Question

A 46-year-old man is brought to the emergency department by the police after being found unresponsive on a nearby park bench.  Previously, the patient was brought to the hospital on several occasions due to acute alcohol intoxication.  No other history can be obtained.  The patient appears disheveled and has a strong smell of alcohol.  Temperature is 36.1 C (97 F), blood pressure is 110/76 mm Hg, and pulse is 84/min.  Pulse oximetry shows 98% on ambient air.  The patient does not follow instructions and withdraws all extremities to painful stimuli.  The mucous membranes are dry, and he has several spider angiomata and bilateral gynecomastia.  The lungs are clear to auscultation and heart sounds are normal with no murmur.  There is moderate abdominal distension with shifting dullness.  The liver edge cannot be palpated.  While being evaluated in the emergency department, the patient vomits a large amount of bright red blood.  Repeat vital signs show that blood pressure is 100/50 mm Hg and pulse is 110/min.  Two large-bore peripheral lines are placed and intravenous fluid is administered. The initial appropriate steps are taken for this patient, and an upper gastrointestinal endoscopy is planned.  Laboratory results are as follows:
 Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Intravenous octreotide should be initiated in this patient with acute upper gastrointestinal (GI) bleeding highly concerning for variceal hemorrhage. Esophageal varices are one of the many complications of elevated portal venous pressure due to cirrhosis. Octreotide is thought to decrease the elevated pressure by decreasing splanchnic blood flow, which may lead to spontaneous resolution of the variceal hemorrhage. Octreotide administration should occur while the patient's condition is being stabilized and is not a substitute for endoscopic therapy. (Choice A) Albumin is a frequent choice for fluid resuscitation in patients with cirrhosis. This patient has already undergone fluid resuscitation, and his condition remains hemodynamically stable. (Choice B) Fresh frozen plasma (FFP) can be used to correct coagulopathies due to vitamin K deficiency and is typically administered when the INR is >2; this patient's INR is 1.5. FFP administration is associated with a risk of volume overload in patients with cirrhosis. In addition, variceal bleeding is due primarily to increased portal venous pressure and vascular changes rather than to coagulopathy, making FFP less beneficial. (Choice C) H2-blocker infusion is not indicated during acute upper GI bleeding due to worsened outcomes, mortality, and rebleeding as compared with proton pump inhibitor therapy. Instead of H2 blockers, intravenous proton pump inhibitors should be considered in this patient (after therapy is started for variceal bleeding) as gastric or duodenal ulcers may cause bleeding. (Choice E) Platelet transfusion is generally indicated in patients with acute GI bleeding with platelets <50,000/mm². This patient does not meet this criterion. Educational objective: In patients with cirrhosis in whom there is concern for variceal hemorrhage, intravenous octreotide should be initiated after stabilization and while awaiting endoscopic therapy. Octreotide is thought to decrease the elevated portal venous pressure that causes variceal formation and may stop the hemorrhage. References: The role of endoscopy in secondary prophylaxis of esophageal varices. (http://www.ncbi.nlm.nih.gov/pubmed/20682237) Acute variceal hemorrhage. (http://www.ncbi.nlm.nih.gov/pubmed/17556146) The art of plasma transfusion therapy. (http://www.ncbi.nlm.nih.gov/pubmed/16934057) Systematic review and net-work meta-analysis of upper gastrointestinal hemorrhage interventions. (http://www.ncbi.nlm.nih.gov/pubmed/27855401)

A 46-Year-Old Man Is Brought to the Emergency Department by the Police