A 43-year-old woman is brought to the emergency department with bloody emesis. Her medical history is significant for idiopathic cirrhosis. The patient was hospitalized 5 months ago for variceal band ligation. On initial evaluation, blood pressure is 88/52 mm Hg, pulse is 121/min, and respirations are 22/min. Pulse oxymetry is 96% on room air. The patient is somnolent and barely arousable to sternal rub. Dried blood is seen around her mouth. The abdomen is distended with a positive fluid shift. There is 1+ peripheral edema. Her hemoglobin is 7.5 g/dL, and the platelet count is 59,000/mm³. The International Normalized Ratio is 1.9. Two large-bore catheters are placed, and 2 L of normal saline are rapidly infused. Despite resuscitation with crystalloids, the patient remains minimally responsive; her blood pressure is 89/49 mm Hg and pulse is 119/min. While still in the emergency department, she continues to have repeated episodes of bloody vomiting with clots. A unit of packed red blood cells is prepared for transfusion. Which of the following is the best next step in management of this patient?

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Quizplus · Accepted Answer

This patient has upper gastrointestinal bleeding with ongoing hematemesis and altered mental status. Given her history of cirrhosis and variceal band ligation, esophageal variceal hemorrhage is the most likely cause. Initial evaluation and management of patients with variceal hemorrhage should focus on maintaining adequate circulation, preventing and treating complications, and stopping the underlying cause of bleeding. Two large-bore catheters have been placed, crystalloid solution has been administered for volume resuscitation, and a packed red blood cell transfusion (which is indicated, despite a hemoglobin >7 g/dL, due to ongoing hemodynamic instability) is being prepared. However, this patient's continued hematemesis (with clots) and depressed level of consciousness are a major risk for aspiration, which could quickly exacerbate her tenuous clinical status. While the patient awaits urgent endoscopic intervention, rapid sequence endotracheal intubation should be performed to prevent airway compromise due to aspiration of blood. Intubation also assists gastroenterologists in performing an upper endoscopy, especially in patients unable to maintain their own airway. Patients with cirrhosis and variceal bleeding should also receive prophylactic antibiotics to prevent spontaneous bacterial peritonitis and a somatostatin analog (eg, octreotide) to reduce variceal hemorrhage and improve hemostasis. (Choice A) Although an abdominal x-ray can be very useful to identify gastrointestinal tract perforation (sudden, severe abdominal or chest pain, subcutaneous emphysema), it rarely provides helpful information in patients with gastrointestinal bleeding. (Choice B) Diagnostic paracentesis could be considered at a later point to evaluate for spontaneous bacterial peritonitis, which can be a complicating factor in patients with cirrhosis and gastrointestinal hemorrhage. However, this is not as important as stabilizing the patient and attempting to stop the bleeding. (Choice D) Nasogastric tube placement may help decompress the stomach and facilitate in the removal of blood for improved visualization prior to endoscopy. However, it is less important than securing the patient's airway and preventing a life-threatening complication. (Choice E) Upper gastrointestinal endoscopy with variceal ligation or sclerotherapy is critical to stop this patient's variceal hemorrhage; however, in patients with significantly altered mental status and persistent hematemesis, it should be performed after the patient's airway is protected. Educational objective: Patients with upper gastrointestinal bleeding who have a depressed level of consciousness and ongoing hematemesis should be intubated to protect the airway as a part of initial stabilization and resuscitation. Prompt endoscopic treatment with ligation or sclerotherapy should then be performed to stop the bleeding. References: Management of variceal and nonvariceal upper gastrointestinal bleeding in patients with cirrhosis. (http://www.ncbi.nlm.nih.gov/pubmed/25177367)

A 43-Year-Old Woman Is Brought to the Emergency Department with Bloody