Critical Care Medicine-Gastrointestinal, Nutrition and Genitourinary Disorders>>>>>Stomach
Question 1#

A 65-year-old woman with a history of smoking and osteoarthritis is recovering well after a cosmetic plastic surgery procedure. On postoperative day 2 she has resumed her home medications including daily aspirin and is being prepared for discharge; however, she becomes newly hypotensive. She is transferred to the ICU with 1 L of normal saline infusing and a blood pressure of 92/60 mm Hg with heart rate 118 beats/min. She is pale, diaphoretic, and agitated. Her incision is clean and dry. Her laboratory test results on arrival to the ICU are notable for Hgb 6.5 mg/dL from 12 mg/dL, last checked two days prior. She then has an episode of hematemesis and her blood pressure drops to 70/40 mm Hg. Transfusion of packed red blood cells is initiated.

Which of the following is the MOST appropriate next step in management of this patient? 

A. STAT CT angiogram of the abdomen
B. Interventional radiology consultation for possible angioembolization
C. Urgent surgical exploration
D. Upper GI endoscopy
E. PRBC transfusion to Hgb ≥10 with no further intervention

Correct Answer is D

Comment:

Correct Answer: D

This patient with hematemesis became hemodynamically unstable because of an upper GI bleed. Smoking, aspirin, and NSAID use (common in patients with osteoarthritis) are among the most important risk factors for peptic ulcer disease (PUD), and in this case the patient likely has an acute bleed from an ulcer. Up to 50% of peptic ulcers are asymptomatic until bleeding occurs, which may present as hematemesis or melena. 

Upper GI endoscopy is the gold standard for diagnosis of PUD and the first-line therapy for bleeding ulcers. This should be performed urgently in the hemodynamically unstable patient as it allows for both diagnosis and treatment (clipping, cautery, or injection of a bleeding vessel). CT angiogram of the abdomen may identify a source of bleeding; however, it is less sensitive than endoscopy for identifying a source of bleeding and does not allow therapeutic intervention. Surgical exploration is associated with a higher risk of complications than endoscopic management and so should not be pursued initially. Angiographic embolization is an alternative to repeat endoscopy or surgical intervention but does not replace the initial endoscopic management of upper GI bleed and may have a higher risk of rebleeding than surgery.

Intravenous fluid resuscitation and transfusion of blood products are essential in the early management of this patient with hypotension and evidence of bleeding. Although resuscitation goals for acute upper GI bleeding vary, restrictive strategies recommend transfusion for hemoglobin <7.0 mg/dL. Transfusion to higher hemoglobin goals (>10 mg/dL) is associated with higher rates of mortality and rebleeding and therefore not recommended (E). 

References:

  1. Li LF, Chan RL, Lu L, et al. Cigarette smoking and gastrointestinal diseases: the causal relationship and underlying molecular mechanisms (review). Int J Mol Med. 2014;34:372-380.
  2. Lanas A, Chan FKI. Peptic ulcer disease. Lancet. 2017;390:613-624.
  3. Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013;368:11-21.
  4. Lau JY, Barkun A, Fan DM, Kuipers EJ, Yang YS, Chan FK. Challenges in the management of acute peptic ulcer bleeding. Lancet. 2013;381:2033- 2043.