Case Study 17: Upper GI Bleeding - CRASH! Medical Review Series

Great work!!

Doing great with these cases :)

(On Friday of February 10, 2023). On the Matter of Upper Gastrointestinal Hemorrhage (Bleeding; Hematemesis, Melana and Hemodynamic Changes) on Clinical Presentation (Vitals: BP 88/60; HR 120, RR 15, T 98.0 ^F Saturation 97% on Room Air): 1) Physical Examination (Px): a) General: Drowsy and Ethanol Infused Aura (Smells like An Alcoholic); b) Skin: Spider Angioma Present (Portal Hypertension); No Pallor (Possible no Anemia), Normal Turgor, and Rashes Negative; c) HEENT: Normocephalic (No JVD), No Injury Manifested, Scleral Icterus (Jaundice of the Eyes Correlates to Alcoholism), PERRLA; d) Chest and Lungs: Clear to Auscultation, and Gynecomastia; e) CV: Tachycardia of 120 without Murmurs; f) Abdomen: 1) Soft, 2) NT/ND, 3) Splenomegaly Present (Palpable Mass Next to Left Costal Margin reveals 2x Enlargement); g) Rectal Examination: Occult Blood Positive; Normal Tone; h) Neurologic/Psychiatric: No Focal Signs and Drowsy but Cognition is Good (Oriented to Person, Place, and Time); SSx: DDx: 1) Esophageal Variceal Hemorrhage; 2) Peptic Ulcer Disease (Ulceration is Often Accompanied With Hemorrhage) can be Suspected when SSx of Heartburn, Active Bleeding, Chronic NSAID use; Endoscopy will show the Ulcers within Stomach and/or Small Intestine (Duodenum); 3) Mallory-Weiss Tear (Esophageal Tear or Lacerations; Or Gastroesopheageal Laceration Syndrome) occur in SSx of Hematemesis (Vomiting of Red, Bright Blood) after a School Party (Binge Drinking). Endoscopy will localize the Injury in the Gastro-Esophageal Junction; Endoscopy will reveal Such Mucosal Lacerations; 4) Erosive Gastritis is Common to Alcoholics but has no Significant Hemorrhage (Early Pathogenic Stage of Liver Disease Correlation); 5) Esophageal Neoplasm (Adenocarcinoma or Squamous Cell Carcinoma) will have Constitutional SSx and History Positive for at Least Dysplasia or Other Neoplastic Process; Dx: 1) Emergent Orders of Priority Because of Active Bleeding: a) Insertion of Two (2) Large Bore IV Lines; b) Bolus of Normal Saline; c) NG Tube Insertion; 2) CBC (Anemia and Possible Infection or Pancytopenia): Hgb at 9.9 mg/dL is Low; Hct is 30.0% and Low; WBC 8,500/mm3; Platelets are 95,000/mm3 and Low; MCV 91 (Normal Volume); 3) BMP (Seven Electrolytes Tests) is Normal; 4) Liver Function Tests (LFTs) AST 270 U/L is High; ALT 95 U/L is High: Bilirubin at 3.9 mg/dL is High; ALP at 158 U/L is also High; 5) PT/PTT for further characterization of the Stage and Degree of Liver Disease) where PT at 19 seconds is High; PTT at 52 Seconds is High; 6) If Anemia is > 7 PRBC will be Necessary for which Typing and Matching is Indicted (Type X Match); and 6) Endoscopic Banding; Tx: 1) Gastroenterology Consult for Emergent Upper Endoscopy (No Peptic Ulcers [otherwise Normal Gastric Mucosa] and no active/ongoing Bleeding); Mx: 1) Stabalization (ABC Methodology); 2) Fluid Replenishment for Hypotension and Dehydration until SBP is > 90 mmHg along with Vitamin B1 (Thiamine Mononitrate); 3) IV Octreotide For Active Variceal Bleeding (Somatostatin) 50 micrograms initially and thereafter at 50 mcg/H (Off-Label Controversial Therapy for Homeostatic, Physiologic Delay of Hormonal Transient Paresis); 4) Emergent Upper Endoscopy upon Stabalization of Patient (Normal BP, HR and RR); 5) Packed Red Blood Cells Transfusion Pending Crossing and Matching, and Anemia of Less than 7 (Maintain at Range of 7-9); 6) Intensive Care Unit Admission and Procedures therein: 1) Maintenance Fluids; 2) Pulse Oximetry; 3) BP Monitoring; 4) Cardiac Monitoring (ECG); 5) Insert Foley; and 6) Input and Output Monitoring (I/O Check); 7) Because Liver Disease of Late-Stage (Cirrhosis Management) is Likely Gastroenterology is an important Specialty to Consult; 8) IV Propranolol once Blood Pressure is Stabalized (Above 100 SBP and 90 DBP and no Significant oscillations); 9) Indication for Fresh Frozen Plasma (FFP) when PT is Elevated; 10) Ceftriaxone (3rd Generation Cephalosporin) as Spontaneous Bacterial Peritonitis (SBP) is a Possible Complication and further Progression of Late-Stage Liver Disease; 11) Discharge upon Stabilization and Treatment on Propranolol (Beta Blockers Non-Cardiac Selective Drug Class); 12) Increase Variceal Surveillance (Every two Years via Endoscopy); 13) Counsel for Alcoholism and Advice Alcohol Cessation (Recommendation); 14) Gastroenterology follow up for Management; and 15) If Varix Banding is Ineffective at Controlling the Hemorrhage, then Transjugular Intrahepatic Portosystemic Shunt (TIPS); Goodness, my first Upper Gastrointestinal Active Bleeding. Not Really. The Subject was far advanced in Liver Disease (End-Stage Liver Disease), and I had to Diagnose (Acute) Hepato-Renal Syndrome Type I, but rapidly progressed to Type II. MD Paul W. Bolin, es gut ist zu lehren und lernen mit Ihnen aber man kann nicht immer dass tun. Heil!

A question sir its upper gi bleed so it could be an esophegeal tear in that case shouldnt ng tube be contraindicated?

Hi Dr . Bolin. With regard to the administration of thiamine in IV administered fluids (assumingly to prevent the acceleration of Wernicke-Korsakoff syndrome in alcoholics): What is the reason to not administer thiamine in all patients who receive IV fluids, since in some instances, the attending physician may not know if the patient is an alcoholic? Being water soluble, thiamine has little danger of overdose. Andre L. Albert (not a physician, but a big fan of all your lectures..I have gained much knowledge about disease processes)