Let's move on to our next case.
A 48-year-old woman presents to the emergency
department with one episode of bright red bloody emesis.
She has a history of alcoholic cirrhosis
complicated by jaundice and ascites.
Her only medications are
furosemide and spironolactone.
Vitals are notable for a blood pressure
of 82/50 mmHg and heart rate 115 bpm.
She is disoriented.
Physical exam shows jaundice, spider angiomata,
distended abdomen with a positive fluid wave
and a firm liver edge palpated
3 cms below the costal margin.
Labs show a hemoglobin of 7.8 (g/dL).
IV fluid resuscitation is started.
So we are asked, what is the
best next step in management?
Let's go through some
key features here.
She is presenting with hematemesis
and she has decompensated cirrhosis.
In addition, on physical exam she
has hypotension and tachycardia
which we now know, indicates
probably severe hypovolemia.
She has physical exam findings of cirrhosis
and anemia on her labs indicating blood loss.
So, we mentioned the term
What that means is there's an
acute deterioration in the liver function
in a patient with cirrhosis
characterized by any of these things:
so they may have new onset jaundice,
they may have developed ascites
or free fluid in the peritoneum,
they may develop hepatic encephalopathy or confusion
or coma related to the build up of toxins,
they may develop hepatorenal syndrome which is a
particular type of kidney injury that we'll discuss later,
or they may present with new onset variceal
hemorrhage, so bleeding from those dilated varices.
So, let's now review how
cirrhosis leads to GI bleeding.
Recall that with portal hypertension, you have back up
of flow and pressure into the portal systemic vessels.
So first, you may have back up of flow
into the esophageal and gastric vessels
leading to varices in those locations.
Next, you may also develop
back up of flow into the splenic vein
leading to enlargement of
the spleen or splenomegaly.
And you may also have back up of flow
into the rectal collateral vessels
leading to hemorrhoids which can
also present with GI bleeding.
So let's talk specifically
about esophageal varices.
Patients often present with
hematemesis and/or melena.
They can be very scary and that
they can cause massive bleeding
and so these patients require very
urgent attention and stabilization.
Here on the right you can see
an example of an upper endoscopy
where you see very dilated tortuous
vessels along the length of the esophagus,
that's what varices appear like.
So the key elements of management are
providing aggressive, supportive care.
So that's fluid resuscitation and/or
transfusion if they meet the parameters.
You should then do upper endoscopy which can be
diagnostic and therapeutic at the same time.
You should give vasoconstricting
medications like octreotide
which will reduce blood flow to the esophageal
area and hopefully reduce the amount of bleeding.
And another important element of
management is giving antibiotic prophylaxis,
This is to prevent the high risk of infections
like spontaneous bacterial peritonitis
that can occur with GI bleeding.
We manage that by giving antibiotics
like ceftriaxone or norfloxacin.
So now that we've reviewed that,
let's return to our case.
A 48-year-old woman, who's now
coming in with hematemesis.
We know that she has decompensated cirrhosis
because of the presence of jaundice and ascites.
So knowing that, we should always
be concerned for a variceal hemorrhage
in a patient with these complaints.
In addition, she has signs of severe hypovolemia
and physical exam findings of cirrhosis.
Note that she's already been
started on IV fluid resuscitation.
So the best next step in
management will be to start octreotide
which is a splanchnic
and giving antibiotic prophylaxis for
spontaneous bacterial peritonitis,
giving a transfusion as needed and
colon GI for an upper endoscopy.
Note here that although her
hemoglobin was 7.8 (x10^9)
and she doesn't quite meet that
threshold of a hemoglobin less than 7 g/dL
because she's actively bleeding and we know
that esophageal varices can bleed very quickly,
you would transfuse her before
she hits that threshold.