A 46-year-old Caucasian female is hospitalized for upper gastrointestinal hemorrhage. She had two episodes of coffee ground colored vomiting during the past twelve hours. She has had intermittent episodes of passage of black stools over the last week. She visited a doctor two days ago and underwent an endoscopy that showed erosive gastritis and mild reflux esophagitis. Omeprazole therapy has been started. Her past medical history is significant for polycystic kidney disease and hypertension. Her most recent serum creatinine level is 4.1 mg/dL. Coagulation studies demonstrate the following results: Which of the following is the best next step in the management of this patient?

Question

A 46-year-old Caucasian female is hospitalized for upper gastrointestinal hemorrhage.  She had two episodes of coffee ground colored vomiting during the past twelve hours.  She has had intermittent episodes of passage of black stools over the last week.  She visited a doctor two days ago and underwent an endoscopy that showed erosive gastritis and mild reflux esophagitis.  Omeprazole therapy has been started.  Her past medical history is significant for polycystic kidney disease and hypertension.  Her most recent serum creatinine level is 4.1 mg/dL.  Coagulation studies demonstrate the following results:  Which of the following is the best next step in the management of this patient?

Quizplus · Accepted Answer

Explanation: Renal dysfunction is associated with an increased tendency to bleed. Impaired platelet function is the major contributor to this tendency, and this is reflected by a prolonged bleeding time. Other coagulation studies, such as prothrombin time (PT), partial thromboplastin time (PTT), and platelet count are usually normal. Correction of the platelet dysfunction is necessary in patients with active bleeding (such as the patient in this case) or those who are about to undergo a surgical procedure. Several available options to correct the abnormality include the following: correction of anemia, administration of desmopressin, dialysis, estrogen treatment, and cryoprecipitate infusion. Desmopressin represents the simplest and least toxic acute treatment of a prolonged bleeding time. It acts by increasing the release of factor VIII:von Willebrand factor multimers from endothelium. (Choice A) Asymptomatic patients do not need any specific therapy. (Choice D)Cryoprecipitate infusion is associated with infectious complications. Its use is limited to patients who are not responding to blood transfusions and desmopressin. (Choice C)Platelet transfusion is not indicated in such patients because their platelet count is usually normal. (Choice E)Any surgery without preceding correction of platelet dysfunction is very dangerous because it can precipitate significant bleeding. Educational Objective: Platelet dysfunction is the major contributor of increased bleeding tendency in patients with renal failure. Desmopressin represents the simplest and least toxic acute treatment of prolonged bleeding in patients with renal dysfunction.

A 46-Year-Old Caucasian Female Is Hospitalized for Upper Gastrointestinal Hemorrhage