Review Question - QID 102594

This patient is presenting with profuse bleeding from his esophageal varices. His Glasgow coma scale is less than 8 (eyes - 2, verbal - 2, and motor - 3) making intubation a priority in his resuscitation.

Hematemesis can occur secondary to peptic ulcer disease, gastritis, esophageal varices, a Mallory-Weiss tear, and Boerhaave syndrome. Variceal bleeding is common in cirrhotics given the high resistance of the liver. Initial management should focus on the ABC's of trauma as these patients are prone to rapid decompensation. Once the patient's airway is secure/protected, the patient is breathing/oxygenating/ventilating well, and blood pressure is being maintained, specific treatment for a variceal bleed can be performed. This may involve transfusing clotting factors (given cirrhotics have an abnormal PT/PTT), proton pump inhibitors, ceftriaxone (as prophylaxis against spontaneous bacterial peritonitis), octreotide, and endoscopy with banding of the varices. Nadolol can be given for prophylaxis against future bleeds.

Incorrect Answers:
Answer 1: Emergency surgery would be indicated to stop the bleeding in abdominal trauma with known bleeding but would only take place after the patient's airway had been secured.

Answer 2: Emergency variceal banding would be appropriate after the patient's airway had been secured while the patient is receiving fluids, blood products, and clotting factors.

Answer 4: IV fluids and fresh frozen plasma could be appropriate management of this patient if he was presenting with only minor hematemesis with a protected airway.

Answer 5: Transfuse blood products would be appropriate if this patient was actively bleeding and his hemoglobin was < 7.0 g/dL or he was losing blood rapidly.

Bullet Summary:
Patients presenting with upper GI bleeding should first have their airway, breathing, and circulation stabilized prior to further treatment.