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. Endoscopy shows esophageal varices with evidence of bleeding, which is treated with band ligation. There is no evidence of gastric or duodenal ulcers. The patient also receives intravenous antibiotics. The bleeding stops and his clinical condition improves. Abdominal ultrasonography shows a nodular, shrunken liver; a patent portal vein; mild splenomegaly; and moderate ascites. The patient is counseled for abstinence from alcohol. At the time of discharge, initiation of which of the following is most appropriate for decreasing the risk of recurrent variceal bleeding in 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. Endoscopy shows esophageal varices with evidence of bleeding, which is treated with band ligation.  There is no evidence of gastric or duodenal ulcers.  The patient also receives intravenous antibiotics.  The bleeding stops and his clinical condition improves.  Abdominal ultrasonography shows a nodular, shrunken liver; a patent portal vein; mild splenomegaly; and moderate ascites.  The patient is counseled for abstinence from alcohol.  At the time of discharge, initiation of which of the following is most appropriate for decreasing the risk of recurrent variceal bleeding in this patient?

Quizplus · Accepted Answer

Explanation: Medical treatment can help reduce the risk of rebleeding in patients with esophageal varices due to portal hypertension. This treatment is considered primary prevention if the patient has not previously had a bleeding episode but has known esophageal varices, whereas treatment for those with multiple bleeding episodes would be classified as secondary prevention. First-line preventive agents are nonselective beta blockers (eg, propranolol, nadolol), which help reduce pressure in the portal venous system. The combination of beta blockers and repeat surveillance endoscopy with band ligation as necessary results in an even lower mortality rate than either treatment alone. The addition of an oral nitrate to beta-blocker therapy may further reduce rebleeding. (Choice A) Furosemide and spironolactone are potent diuretics that decrease volume overload and ascites associated with cirrhosis. They do not have a role in preventing further bleeding episodes. (Choice B) A hydralazine and nitrate combination has mortality benefits in some patients who have congestive heart failure with decreased ejection fraction. (Choice D) Proton pump inhibitors would be used to prevent repeat upper gastrointestinal hemorrhage from peptic ulcer disease as they reduce gastric acid formation. They do not significantly affect esophageal varices. (Choice E) Vitamin K supplementation is used for coagulopathies due to nutritional deficiencies and warfarin. This patient's mild elevation in INR is likely due to hepatic dysfunction from cirrhosis and would not reverse with vitamin K. Supplementation would not decrease bleeding risk. Educational objective: Nonselective beta blockers (eg, nadolol, propranolol) can be used in the primary and secondary prevention of esophageal variceal hemorrhage, particularly in combination with endoscopic surveillance and band ligation. References: Prevention of recurrent esophageal variceal hemorrhage: review and current recommendations. (http://www.ncbi.nlm.nih.gov/pubmed/17975483)

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