Gastrointestinal bleeding: The Daily PANCE Blueprint
A 62-year-old man presents to the emergency department with a 2-day history of black, tarry stools and a single episode of vomiting bright red blood this morning. He denies any abdominal pain, recent travel, or use of nonsteroidal anti-inflammatory drugs (NSAIDs). His medical history is significant for chronic alcohol use and peptic ulcer disease. Vital signs on presentation are: blood pressure 90/60 mmHg, heart rate 110 beats/min, respiratory rate 18 breaths/min, and temperature 37°C. Physical examination reveals mild pallor and a soft, non-tender abdomen. Laboratory tests show a hemoglobin level of 7.8 g/dL and a mean corpuscular volume (MCV) of 92 fL. An urgent upper gastrointestinal endoscopy reveals a clean-based ulcer on the posterior wall of the duodenum. Which of the following is the most appropriate next step in management?
A. Immediate surgical intervention
B. Thermal coagulation of the ulcer
C. Intravenous proton pump inhibitors
D. Oral proton pump inhibitors
E. Administration of intravenous corticosteroids
Answer and topic summary
The answer is C. Intravenous proton pump inhibitors
In a patient presenting with upper gastrointestinal bleeding (UGIB) and findings suggestive of a peptic ulcer, the initial management should include resuscitation (if necessary) and stabilization of the patient, followed by the administration of intravenous proton pump inhibitors (PPIs). PPIs reduce gastric acid secretion, promote clot stability, and are associated with reduced rates of rebleeding, surgery, and mortality. This approach is particularly important in patients with risk factors such as chronic alcohol use and a history of peptic ulcer disease.
Incorrect Answers:
A. Immediate surgical intervention: Surgical intervention is reserved for cases where endoscopic treatment fails or is not available, or in cases of perforation or ongoing massive bleeding that cannot be controlled endoscopically. Since the ulcer in this scenario is clean-based and there’s no mention of failed endoscopic control, immediate surgery is not indicated.
B. Thermal coagulation of the ulcer: While endoscopic thermal coagulation is a treatment option for bleeding ulcers, it is not the most appropriate next step in management for a clean-based ulcer without active bleeding. Initial management should focus on medical therapy with PPIs to stabilize the patient and reduce the risk of rebleeding.
D. Oral proton pump inhibitors: Although oral PPIs are effective in the management of peptic ulcers, in the setting of acute bleeding and hemodynamic instability, intravenous administration is preferred to ensure adequate absorption and more immediate effect.
E. Administration of intravenous corticosteroids: Corticosteroids have no role in the management of peptic ulcer disease or acute gastrointestinal bleeding. Their use is primarily in inflammatory conditions such as inflammatory bowel disease.
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Covered under ⇒ PANCE Blueprint GI and Nutrition ⇒ ⇒
