Case 3: Diagnostic Testing

Here are the initial lab results:

Based on these results, what are the appropriate next steps?
Transfuse PRBCs
Excellent choice!
Transfusion Goal for Acute variceal UGIB: Hgb > 7 since over transfusing can increase portal pressures and exacerbate bleeding!
Dose Antibiotics
Excellent choice! This patient has a history of cirrhosis and has an UGIB, antibiotics have been shown to reduce the risk of mortality, infections and rebleeding. Ceftriaxone is first line therapy given its good gram negative bacterial coverage.
Initiate Octreotide
Excellent choice! Octreotide is a somatostatin analog which inhibits the release of vasodilator hormones and causes splanchnic vasoconstriction thereby decreasing portal inflow and has been proven to decrease mortality and improve hemostasis in variceal bleeds.
Dose Proton Pump Inhibitor (PPI)
Excellent choice! PPIs neutralize gastric acid and stabilize blood clots.
Dose FFP
This should not be the next step. Trials have not shown a benefit with correcting the INR with either FFP or factor VIIa. Additionally, the INR is not a reliable indicator of coagulopathy in cirrhotic patients. Try again!
Balloon tamponade
This should not be the next step. Balloon tamponade is good for short term hemostasis for temporary stabilization until more definitive treatment. However, rebleeding is common upon deflation and there is also risk of esophageal necrosis or rupture. Try again!
Excellent Choice! Patient has a history of cirrhosis and is now presenting with hematemesis and anemia. Urgent Endoscopy for both diagnostic and therapeutic purposes should be performed as soon as the patient has been adequately resuscitated.
CT Angiography
This isn’t an appropriate next test. While it can reveal an active GI bleed, it is more useful for lower GI bleeding and this patient’s presentation is more concerning for an upper GI bleed. It will also expose the patient to radiation unnecessarily. Try again!
This isn’t an appropriate next test. Although this patient has melena, he is presenting with bright red emesis which is more suggestive of an upper GI source. Try again!

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