Question Of The Day #99

This patient arrives to the Emergency department after a single hematemesis episode.  On exam he has a borderline low blood pressure and tachycardia.  The laboratory results demonstrate an elevated BUN and a low hemoglobin and hematocrit.  The patient’s vital signs in combination with the laboratory values point towards a diagnosis of an upper GI bleed with early signs of hemorrhagic shock.  The history of alcohol abuse also should raise concern for possible gastro-esophageal variceal bleeding as the cause of the GI bleed.

Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

Although this patient is not acutely unstable, his vital signs are abnormal and he should receive volume resuscitation and close observation in the Emergency department.  After initial resuscitation and treatment, it is sometimes difficult to know the best disposition for the patient (admit versus discharge).  The Glasgow-Blatchford Score isa validated risk satisfaction tool used to assist in determining the disposition of patients with an upper GI bleed.  The scoring criteria and instructions on how to use the score are below.

Instructions:

Low risk= Score of 0.  Any score higher than 0 is high risk for needing intervention: transfusion, endoscopy, or surgery. Consider admission for any score over 0. 

This patient has a Glasgow-Blatchford score of 15, and should not be discharged home.  A plan to discharge with gastroenterology follow up in 1 week (Choice A) or discharge with instructions to return if there are repeat hematemesis episodes (Choice B) should not be followed. This patient may have future hematemesis episodes in the Emergency department, be at risk for aspiration, require endotracheal intubation, and become more hypotensive.  A Sengstaken-Blakemore tube (Choice C) is a specialized oro-gastric tube with a gastric and esophageal balloon.  Placement of this tube is considered an invasive procedure that is only used after a patient has been endotracheally intubated to prevent aspiration.  Once placed correctly, the balloons in the tube can be inflated to tamponade any bleeding variceal vessels in the distal esophagus or stomach.  This tube is used as a last resort measure prior to endoscopic treatment for presumed gastro-esophageal variceal bleeds. 

The best advice for this patient would be to admit the patient for monitoring and endoscopy (Choice D).