Tuesday, 4 October 2011
gi bleed
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A 49-year-old man presents to the emergency room because of melena of 3 days' duration. He denies 
abdominal pain. Vital signs reveal a resting pulse of 104 per minute and a 25-mm Hg orthostatic drop in BP. Physical findings include bilateral temporal wasting, pale conjunctivae, spider angiomas on his upper torso, muscle wasting, hepatosplenomegaly, and hyperactive bowel sounds without abdominal tenderness to palpation. His stool is melenic. Nasogastric tube aspiration reveals coffee grounds material. Hematocrit is 31%. The appropriate next step in the management of this man's illness would be to
abdominal pain. Vital signs reveal a resting pulse of 104 per minute and a 25-mm Hg orthostatic drop in BP. Physical findings include bilateral temporal wasting, pale conjunctivae, spider angiomas on his upper torso, muscle wasting, hepatosplenomegaly, and hyperactive bowel sounds without abdominal tenderness to palpation. His stool is melenic. Nasogastric tube aspiration reveals coffee grounds material. Hematocrit is 31%. The appropriate next step in the management of this man's illness would be toA. Pass a Sengstaken-Blakemore tube.
B. Obtain an upper GI series.
C. Insert a transjugular intrahepatic portosystemic shunt (TIPS).
D. Obtain immediate visceral angiography.
E. Perform upper endoscopy
Explanation:
After this patient has been hemodynamically stabilized, the next mostimportant step is to perform a diagnostic/therapeutic upper endoscopy. If the source of his bleeding is from esophageal varices, then these can be obliterated with sclerosis or, preferably, endoscopic band ligation. The use of a Sengstaken-Blakemore tube should be reserved for patients in whom upper endoscopywas unsuccessful in controlling the hemorrhage. A TIPS should be considered in patients in whom medical and endoscopic therapy have failed. Barium studies have no role in the evaluation of patients with suspected variceal hemorrhage
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