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?
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).
A 25-year-old man is the unrestrained driver in a head-on motor vehicle collision. He arrives with a Glasgow Coma Score of 5 and is intubated in the trauma bay. CT head demonstrates skull fractures with subdural and subarachnoid hemorrhage requiring craniotomy. Postoperatively he is admitted to the ICU intubated and sedated. On postoperative day 6 his nurse notices that his orogastric tube aspirate has become red-brown with coffee-ground appearance.
What is the BEST way to avoid this complication?
Correct Answer: C
This patient is critically ill with traumatic brain injury and has been intubated for over 48 hours. Greater than 40% of mechanically ventilated patients may develop evidence of GI bleeding. Traumatic brain or spinal cord injury has also been associated with stress ulcer development. Stress ulcers are generally attributed to an imbalance in mucosal protection and gastric acid production. There is not clear evidence for superiority of histamine H2-receptor antagonists versus proton pump inhibitors for stress ulcer prophylaxis and either may be used. The use of prophylactic heparin is not associated with an increased risk of upper GI bleeding. Critically ill intubated patients frequently require gastric decompression and/or enteral feeding access, and orogastric tube is a reasonable choice. Early enteral feeding is protective against stress ulcer development, and in addition provides nutritional support necessary in critically ill patients, and should not be withheld. Although H. pylori may contribute to stress ulcer development, there is nothing to suggest that this patient has a peptic ulcer related to H. pylori infection, and he should not be treated prophylactically.
A 65-year-old man with a history of hypertension, GERD, and chronic low back pain presents with vague chest pain. He takes oxycodone, gabapentin, and ibuprofen daily. He is admitted for observation and cardiac workup. EKG shows nonspecific T-wave changes and laboratory test results are unremarkable. On hospital day 2 he has:
His abdomen is distended with tap tenderness and guarding on mild palpation in all four quadrants. Upright chest X-ray demonstrates free air under the diaphragm.
Which of the following is the MOST appropriate next step in management?
Correct Answer: E
This patient’s chronic NSAID use puts him at risk of developing PUD. Patients with PUD may be asymptomatic or have a history of dyspepsia. Nearly half of patients with PUD also experience acid regurgitation symptoms. This patient’s presenting complaint was chest pain, but his cardiac workup is unremarkable. Acid reflux and epigastric pain are frequently confused with chest pain, as was likely in this case. When the patient subsequently developed acute abdominal pain with hypotension, peritoneal signs, and evidence of free air, a perforated ulcer should be high on the differential. Repeating the cardiac workup would delay care and potentially have distracting findings related to cardiac demand. With free air on upright chest X-ray, taking a hemodynamically unstable patient to the CT scanner is an unnecessary delay. Similarly, monitoring him with serial abdominal examinations would be unsafe. Although upper endoscopy is the most accurate diagnostic test for PUD with up to 90% sensitivity in detecting a lesion, in this unstable patient, it would not allow for definitive management of his perforated ulcer. This patient needs a surgical consultation for identification and repair of his perforated peptic ulcer.
A 55-year-old man with hypertension, anxiety, and type 1 diabetes mellitus recently adjusted his medication regimen and began taking clonidine. He presents now with abdominal pain and nausea. This has been associated with occasional episodes of emesis of gastric contents over the past few weeks. His weight is unchanged. His vital signs are within normal limits. On physical examination, his abdomen is distended with moderate tenderness in the epigastrium, but no rebound or guarding. His electrolytes are unremarkable and his finger stick glucose is 350 mg/dL. Upper endoscopy and CT scan show large amount of gastric contents with no evidence of mechanical obstruction.
In addition to reviewing his medication list, what is the BEST next step in caring for this patient?
Correct Answer: B
Gastroparesis, or delayed gastric emptying, is the motility disorder in which food remains in the stomach for a prolonged period of time. This typically presents with postprandial fullness, nausea, vomiting, pain, and/or bloating. It may be due to a variety of factors. Medications that prolong gastric emptying include alpha-2-adrenergic agonists (such as clonidine, which this patient is taking), narcotics, calcium channel blockers, tricyclic antidepressants, and incretin-based diabetes medications. Diabetes mellitus is also a risk factor for gastroparesis, with type 1 diabetics at greater risk than type 2. Once mechanical obstruction has been ruled out, the first-line therapy in gastroparesis is dietary modification and optimization of glycemic control. Large meals and foods high in fat or fiber should be avoided. In this patient, there is no mechanical obstruction and there is no current complaint of emesis, making nasogastric decompression unnecessary. Similarly, there is no mention of ulcerative disease on his endoscopy and therefore no indication for proton pump inhibitors. Gastrostomy tube is very rarely indicated in gastroparesis, and certainly not in this patient with recent onset of mild symptoms who has not yet tried lifestyle or medical management. Gastrojejunostomy can be used to bypass a mechanical gastric outlet obstruction but will not improve the motility of the stomach.
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