A 63-year-old man comes to the emergency department due to easy fatigability and mild abdominal discomfort over the past several days. He also has had intermittent episodes of black-colored stool but has had no chest pain, palpitations, or syncope. His medical history is significant for hypertension, hyperlipidemia, and osteoarthritis. The patient takes amlodipine, lisinopril, and simvastatin. He also takes over-the-counter ibuprofen for hip and back pain that has been "acting up" over the past few weeks. The patient does not use tobacco or illicit drugs and drinks alcohol occasionally. Temperature is 37 C (98.6 F), blood pressure is 106/64 mm Hg supine and 100/72 mm Hg after 3 minutes of standing, and pulse is 98/min. The patient appears pale but is otherwise in no distress. Lung auscultation is normal. Cardiac examination is unremarkable. The abdomen is soft and nondistended with mild epigastric tenderness and hyperactive bowel sounds. Rectal examination shows occult blood-positive melenic stool. Laboratory results are as follows: Adequate venous access is established, and intravenous crystalloids and pantoprazole are started. Preparation for upper gastrointestinal endoscopy is made. Which of the following is the most appropriate next step in management of this patient?

Question

A 63-year-old man comes to the emergency department due to easy fatigability and mild abdominal discomfort over the past several days.  He also has had intermittent episodes of black-colored stool but has had no chest pain, palpitations, or syncope.  His medical history is significant for hypertension, hyperlipidemia, and osteoarthritis.  The patient takes amlodipine, lisinopril, and simvastatin.  He also takes over-the-counter ibuprofen for hip and back pain that has been "acting up" over the past few weeks.  The patient does not use tobacco or illicit drugs and drinks alcohol occasionally.  Temperature is 37 C (98.6 F), blood pressure is 106/64 mm Hg supine and 100/72 mm Hg after 3 minutes of standing, and pulse is 98/min.  The patient appears pale but is otherwise in no distress.  Lung auscultation is normal.  Cardiac examination is unremarkable.  The abdomen is soft and nondistended with mild epigastric tenderness and hyperactive bowel sounds.  Rectal examination shows occult blood-positive melenic stool.  Laboratory results are as follows:  Adequate venous access is established, and intravenous crystalloids and pantoprazole are started.  Preparation for upper gastrointestinal endoscopy is made.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Studies show that most hemodynamically stable patients, including those with upper gastrointestinal (GI) bleeding, have better outcomes with restrictive red blood cell transfusion (eg, transfusion for a hemoglobin level <7 g/dL) than with liberal transfusion (transfusion for a hemoglobin level <9 g/dL). Restrictive transfusion may be associated with fewer complications (eg, transfusion reactions), fewer rebleeding episodes, and decreased mortality. Given his occult blood-positive melenic stools, blood urea nitrogen-to-creatinine ratio >20:1, and recent nonsteroidal anti-inflammatory drug use for hip and back pain, this patient likely has upper GI bleeding and requires proton pump inhibitor therapy and upper endoscopy. This patient is hemodynamically stable, has a hemoglobin level >7 g/dL, and has no symptoms of severe anemia (eg, chest pain, syncope); therefore, he should be closely monitored but he does not require packed blood cell transfusion. In patients with anemia, fatigue and exertional symptoms (eg, dyspnea) are not generally considered indications for transfusion. In addition, although melena indicates the presence of blood, it does not indicate active bleeding. A hemoglobin level >8 g/dL is recommended in patients with stable coronary artery disease or in those planning to undergo major surgery (eg, certain orthopedic procedures). Patients with acute coronary syndrome, severe thrombocytopenia, or cancer with a high bleeding risk may require a higher transfusion goal. Those with massive bleeding and hemodynamic instability might require blood transfusion regardless of hemoglobin levels, as initial levels may not accurately reflect the amount of blood loss (Choice D). (Choice A) Albumin infusion can be considered in the setting of spontaneous bacterial peritonitis or large-volume paracentesis. However, it has not been shown to be more effective than crystalloids for resuscitation during acute GI bleeding. (Choice C) Octreotide is recommended for upper GI bleeding due to variceal hemorrhage. This patient has no evidence of liver cirrhosis (ie, no ascites, only occasional alcohol use), making variceal bleeding less likely. (Choice E) Platelet transfusion can be considered in patients with life-threatening bleeding and platelets <50,000/mm³ or in those taking antiplatelet agents; this patient does not meet either of these criteria. Nonsteroidal anti-inflammatory drugs (eg, ibuprofen) can cause transient thrombocytopenia or platelet dysfunction, but these effects are quickly reversible. Educational objective: The threshold for blood transfusion in most stable patients with upper gastrointestinal bleeding is a hemoglobin level <7 g/dL as this is associated with fewer complications and reduced mortality. Patients with stable cardiovascular disease may benefit from maintaining a hemoglobin level >8 g/dL, and patients with acute coronary syndrome or malignancies with risk of bleeding may require higher transfusion thresholds. References: Transfusion strategies for acute upper gastrointestinal bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/23281973) Restrictive vs liberal transfusion for upper gastrointestinal bleeding: a meta-analysis of randomized controlled trials. (http://www.ncbi.nlm.nih.gov/pubmed/24187470) Clinical Practice Guidelines from the AABB: red blood cell transfusion thresholds and storage. (http://www.ncbi.nlm.nih.gov/pubmed/27732721)

A 63-Year-Old Man Comes to the Emergency Department Due to Easy