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A 37-year-old man comes to the emergency department because of the abrupt onset of crampy abdominal pain and "bright red blood oozing" from his mouth. There were no episodes of emesis preceding the hematemesis. The patient has a past medial history significant for alcoholic cirrhosis documented by liver biopsy 3 years ago. He has been poorly compliant with medications and has not been seen by a physician for over 2 years. He continues to drink 6-12 beers per day. His blood pressure is 90/40 mm Hg and pulse is 90/min. Physical examination shows scleral icterus, clear lung fields, a distended and tense abdomen with a fluid wave, and diffuse spider angiomata on his chest and abdomen. There is no asterixis. You send him for upper endoscopy, which reveals grade three esophageal varices with no active bleeding. These varices are sclerosed. He is admitted to the hospital. The most appropriate next step in management to prevent morbidity is to
A. admit the patient to the ICU for a re-endoscopy in 48 hours
B. begin intravenous octreotide therapy
C. observe the patient for 48 hours and then discharge to home
D. perform an immediate portal-systemic shunt operation
E. transfuse the patient to a hematocrit greater that 30%
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I will choose D becasue you will treat the cause. and the contraindication for Portal shunt is encephalophaty and this patient doesnt have it so i will go with D. Octreotide will be a nice option if this patients doest have cirrhosis.
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The correct answer is B. About 30-60% of variceal bleeding episodes stop spontaneously. Therefore, in the setting of a presumed upper gastrointestinal (UGI) bleed when an endoscopy shows varices but no active lesions, banding and intravenous somatostatin or its analogue, octreotide, are indicated. These agents are vasodilators that cause a reflex increase in splanchnic vessel tone and thus serve to decrease bleeding. This is the standard of care for GI bleeds from varices.
Admitting the patient to the ICU for a re-endoscopy in 48 hours (choice A) is not indicated as the patient appears hemodynamically stable and does not require ICU monitoring.
Observe the patient for 48 hours and then discharge to home (choice C) is not acceptable since most centers choose to re-endoscope patients prior to discharge.
Performing an elective portal-systemic shunt operation (choice D) is certainly an option in the secondary prevention of UGI bleeds due to varices. It is a highly effective option. The drawback is that the procedures are associated with a significant incidence of hepatic encephalopathy. As such, there is no indication to refer all patients with variceal bleeds for elective shunt therapy, but the option should be offered to them.
Transfuse the patient to a hematocrit greater that 30% (choice E) is a "trigger" often taught but the decision to transfuse a patient should be based upon the patient's clinical condition and not a number. If the patient is stable and the bleeding has been controlled, there is no absolute reason why a hematocrit greater than 30 must be attained. There is in fact recent literature that suggests some critically ill patients do worse with a more aggressive transfusion strategy (Hct >30) compared to a more permissive goal (Hct >24).
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You are right, Now I will ask you in this way. Patient come to the ED with Hematemesis fisrt time. in phisical exam you find BP 90/80 HR:100 RR18. no symptoms or sign of cirrhosis or liver dysfuction you do ABC and do an endoscopy adn you fund Varices esophageal no active bleeding. you admint the patient to the ICU for observation treat with octreotic, the next 72 hours patient asyntomatic you do an other Upper GI endoscopy and everything is OK. you decided discharge the patient. what is the best treatment to prevent the recurrency on this patient:
1-Portal Systemic shunt
2-Nitrates
3-Mannitol
4-Propanolo
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try again. This is a patient with fisrt time with varices esophageal uncomplciated which is the treatment?
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ur question was: prevent the recurrency not treatment
