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A 46 y/o male with an abrupt onset of hematemesis


A 46 y/o male with an abrupt onset of hematemesis


حالة سريرية

الوصف الكامل Background
A 46 year old man with a history of alcoholism and known cirrhosis comes to the ER because of the abrupt onset of hematemesis. On physical examination, he is obtunded and confused. Temperature is 37.7 C, pulse rate is 100/min and regular, respiration rate is 20/min and BP is 90/60. He is not jaundiced. Rectal examination discloses black, tarry stool in the rectal vault. Hemoglobin is 10.6 g/dL, the platelet count is 70,000, the INR is 2.4, and serum albumin is 3.

Which of the following has the lowest priority in the initial managment of this pt?
A) Immediated upper endoscopy
B) Fluid resuscitation
C) Endotracheal intubation
D) Transfer to the intensive care unit

Hot sauce's picture
by
طبيب مقيم


answeris A
always stabilize the GI bleeding patient before any specific diagnostic/therapeutic intervenstion

so the ABCs take the priority and the ICU admission is a priority here too because of the massive bleeding

Dr_Ayyad
بعد التخرج

Let me add the following Question:
All The following is essential and acceptable in the manegment of this patient except
A - Starting patient on Octreotide/ Sandostatin bolus then drip
B- Starting Patient on proton pump inhibitor IV bolus then drip
C- Inserting a Sengstaken-Blackmore tube to compress the esophageal bleeding varices and stop their bleeding
D- Correcting patient coagulopathy with Vit K and or FFP
E -Starting patient on broad spectrum antibiotic like ceftriaxone
ABIM's picture
ABIM


it's d.

giving a patiant with cirrhosis vitamin k will do no help in correcting his coagulatory status coz the liver is unable to build thrombotic agents no mattet how much vit k is there..

better to transfuse him with fresh plasma.

dr.tabban's picture
dr.tabban


I would go for C 7akeem

the Sengstaken-blackmore is only used as a last resort if sclerotherapy /banding fails and only as atemporary bridge till a more definite intervention can take place - TIPS for example

discussion -
A-these may be beneficial in decreasing in the extent of variceal bleeding
b- in 50% of patients with known varices UGI bleeding may be due to peptic ulcer and PPI given IV are very effective in such a case : the decrase bleeding,recurrence rate morbidity and mortality

d-sure and for known liver disease vit K may be ineffective so FFP is the alternative

e-well,may be ab can be beneficial in decreasing the cahnce of develpoing hepatic encephalopathy by decreasing nuber of bacteria that colonize the bowel and produce NH3-especially GI bleeders w liver disease are very prone to encephalopathy

Dr_Ayyad
بعد التخرج


I asked this same question in the GI case 1 but no body answered

dado's picture
dado
بعد التخرج


As the problem mentioned that the pt. is cerrhotic and so the cuz is mostly bleeding from esophageal varices I would choose

Quote:
B- Starting Patient on proton pump inhibitor IV bolus then drip

becuz anti ulcer isn't essential in such case

dr_bashar_x2's picture
dr_bashar_x2

Quote:
becuz anti ulcer isn't essential in such case

in 50% of patinets with known varices and UGI bleeding , the culprit is a PU not the varices !!!! and even if u prove that the varices are the source of the bleeding PPIs are still indicated and should be given till the varices oblitrate (after endoscopic intervention)

Dr_Ayyad
بعد التخرج

Well !! Does that mean we intubate any pt with UGI Bleeding ??? I doubt that !!!.....what do u think dr.ABIM ???............thanks all
sopy's picture
sopy
طالب دراسات عليا


no sopy
it is just to stress on ABCs
note that in this example the patient is obtunded
an obtunded patient cant protect his airway and may asphyxiate with his own blood
so u have to have alow threshold for intubation

Dr_Ayyad
بعد التخرج


lets summarize things
regarding Hot sauce case
always ABCs take the priority
in this patient intubate to protect the airway,repalce volume and admit to ICU as it has the looks of a massive bleed
only when the patient is clinically stable proceed w specific dx/therapeutic interventions

regarding dr.ABIM's question
the octreotide/sandostatin which are somatostatin analogue which may help to decrease bleeding from varcices,PPI may be used in all UGI bleeders even those with known varices because of the high incidence of bleeding PUD and in the case of variceal bleeding,PPI should be given till the varcies get oblitrated w banding therapy
the blackmore tube is used only after all therapeutic options fail and is only a temporary measure till a more definite procedure can be performed -TIPS for example

Dr_Ayyad
بعد التخرج


Can't add anything . YOu said it all Dr Ayyad

In regrad to antibiotics in cirrhosis with GI bleed it is a must and ample evidence to make this standered of care and the reason is as Dr Ayyad said : to prevent hepatic encephalopathy.

I have one comment that was made with over enthusiasm but lacks evidence to support it: PPI in PUD may reduce rebleedbing ,units of blood transfused ( morbidity) but there is no evidence to support that it alters mortality.

ABIM's picture
ABIM


thanx 7akeem

Dr_Ayyad
بعد التخرج

Thank you Dr.Ayyad,Dr.ABIM & hot Sauce very much..........
sopy's picture
sopy
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