Question Of The Day #96

This patient arrives to the Emergency department with upper abdominal pain and hematemesis.  The exam demonstrated hypotension, tachycardia, pale conjunctiva, and abdominal ascites. The patient decompensates during the exam requiring endotracheal intubation for airway protection. This patient has an upper GI bleed most likely from gastro-esophageal varices given her history of liver cirrhosis and stigmata of chronic liver disease.  Gastro-esophageal (GE) varices are dilated blood vessels at the GE junction that result from portal hypertension.  Variceal bleeding can be catastrophic and cause hemorrhagic shock and problems with airway patency as seen in this scenario.  The management of GE variceal bleeding, like other GI bleeds, begins with management of the “ABCs” (Airway, Breathing, and Circulation).  Unlike in other causes of upper GI bleeds, IV antibiotics and IV octreotide are used in GE variceal bleeds.  IV antibiotics have a mortality benefit when used in this setting.  First line antibiotics are IV ceftriaxone or IV ciprofloxacin.  Early gastroenterology consultation is another important component of GE variceal bleed management for definitive diagnosis and treatment with variceal banding or ligation.  

An abdominal paracentesis (Choice A) is not the best next step in this unstable cirrhotic patient.  Antibiotics are routinely given in gastro-esophageal variceal bleeds due to their mortality benefit, so there is no need for an emergent paracentesis to evaluate for spontaneous bacterial peritonitis (SBP) with an ascitic fluid sample. IV Tranexamic acid (Choice C) is an anti-fibrinolytic agent with pro-coagulative effects.  Its use is recommended in post-partum hemorrhage and traumatic hemorrhages, but it has no utility in the setting of GI bleed.  Early gastroenterology consultation for endoscopy is preferred over general surgery consultation (Choice D).  Surgery consultants can assist in a TIPS procedure (Transjugular intrahepatic portosystemic shunt) to reduce portal hypertension, esophageal resection, or gastrectomy, but less invasive endoscopic therapies with GI specialists are preferred over these procedures.

IV Ceftriaxone (Choice B) is the best next step in this scenario due to the mortality benefit of antibiotics in chronic liver disease patients with variceal bleeds.      

Please see the chart below for further details on general GI bleed causes, signs and symptoms, and ED management.