A 68-year-old man is brought to the emergency department after an episode of coffee-ground emesis followed by lightheadedness. He has had black, tarry stools for the past few days. The patient has been taking over-the-counter ibuprofen for osteoarthritis. His other medical problems include hypertension and removal of 2 hyperplastic colon polyps 4 years ago. The patient drinks 2 or 3 beers on weekends. He does not smoke. Temperature is 36.7 C (98 F), blood pressure is 112/72 mm Hg, pulse is 110/min, and respirations are 16/min. His lungs are clear to auscultation. The abdomen is slightly tender to deep palpation in the epigastrium. Laboratory results after the initial resuscitation are as follows: In addition to intravenous fluid resuscitation, which of the following is the most appropriate next step in management of this patient?

Question

A 68-year-old man is brought to the emergency department after an episode of coffee-ground emesis followed by lightheadedness.  He has had black, tarry stools for the past few days.  The patient has been taking over-the-counter ibuprofen for osteoarthritis.  His other medical problems include hypertension and removal of 2 hyperplastic colon polyps 4 years ago.  The patient drinks 2 or 3 beers on weekends.  He does not smoke.  Temperature is 36.7 C (98 F), blood pressure is 112/72 mm Hg, pulse is 110/min, and respirations are 16/min.  His lungs are clear to auscultation.  The abdomen is slightly tender to deep palpation in the epigastrium.  Laboratory results after the initial resuscitation are as follows:  In addition to intravenous fluid resuscitation, which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This patient's presentation (hematemesis, melena, anemia, and a blood urea nitrogen to creatinine ratio >20) is consistent with upper gastrointestinal bleeding (UGIB), likely due to nonsteroidal anti-inflammatory drug use. Supportive measures for UGIB include supplemental oxygen, bowel rest, and intravenous fluids through large-bore catheters. An intravenous proton pump inhibitor should also be administered for acid suppression. Packed red blood cell (PRBC) transfusion can increase oxygen-carrying capacity in patients with significantly low hemoglobin levels. In general, stable patients without significant comorbid conditions should receive PRBC transfusion for hemoglobin <7 g/dL. A higher threshold of hemoglobin <9 g/dL can be considered for patients with acute coronary syndrome. Patients with active bleeding and hypovolemia may need PRBC transfusion at higher hemoglobin levels due to the initial hemoglobin concentration not fully reflecting blood loss. In addition, the hemoglobin level may drop significantly as blood volume is replaced by the infusion of crystalloid solutions and the mobilization of interstitial fluid. (Choice A) Fresh frozen plasma contains all clotting factors and plasma proteins from one unit of blood. It is usually indicated for severe coagulopathy (eg, liver disease, disseminated intravascular coagulation) with active bleeding. Fresh frozen plasma is generally not needed to correct a minimally abnormal INR (<1.6), which is a common finding in gastrointestinal bleeding. (Choice B) Proton pump inhibitors reduce rebleeding and the need for transfusions, and help stabilize clots in patients with UGIB. Histamine-2 blockers, such as famotidine, have not demonstrated such benefits and consequently are not recommended as first-line therapy for UGIB. (Choice C) Somatostatin analogs such as octreotide are a mainstay in management of variceal bleeding. This patient has relatively limited alcohol use and no manifestations of cirrhosis, making variceal bleeding less likely. (Choice E) Platelet transfusions are typically given for a platelet count <10,000/mm³ (increased risk of spontaneous hemorrhage) or for a platelet count <50,000/mm³ with active bleeding. (Choice F) Whole blood transfusion, which includes PRBCs in addition to plasma, may be used in patients with severe hemorrhage (eg, major trauma) requiring massive blood transfusions to assist in volume expansion. Educational objective: Packed red blood cell transfusions are recommended in acute gastrointestinal bleeding for patients with hemoglobin <7 g/dL. A higher threshold of hemoglobin <9 g/dL is considered for unstable patients with acute coronary syndrome or with active bleeding and hypovolemia. References: Red blood cell transfusion: A clinical practice guideline from the AABB*. (http://www.ncbi.nlm.nih.gov/pubmed/22751760) Transfusion strategies for acute upper gastrointestinal bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/23281973) Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. (http://www.ncbi.nlm.nih.gov/pubmed/22513904)

A 68-Year-Old Man Is Brought to the Emergency Department After