What’s The “Take Home”?- Question
Alcoholic Man With Melena and Hematemesis
During the past 24 hours, a 56-year-old man has experienced melena and 2 episodes of hematemesis. He has biopsy-proven cirrhosis that resulted from heavy, prolonged alcohol consumption; however, he no longer drinks. Previous endoscopy revealed esophageal varices.
The patient has never had encephalopathy, upper GI bleeding, or jaundice. His weight is stable, his appetite is good, and his abdominal girth has not increased. He has no history of significant cardiac disease, chronic obstructive pulmonary disease, diabetes, or hypertension. He takes ibuprofen, as needed, for degenerative disease in a number of large and small joints.
The patient is alert. Blood pressure is 100/60 mm Hg, and heart rate is 100 beats per minute; he has no fever. Lungs are clear, and heart is normal. No scleral or mucosal jaundice is noted. The abdomen is not distended, and no fluid wave can be elicited. There is no palpable hepatosplenomegaly or abdominal mass. Several beats of asterixis are noted, but the patient is otherwise neurologically intact. Two spider angiomas are present on his left shoulder. Findings from the remainder of the examination are normal.
Hemoglobin level is 11.5 g/dL; creatinine, 0.9 mg/dL; bilirubin, 2.4 mg/dL; and albumin, 3.3 g/dL. Prothrombin time is 16.5 seconds (control, 12 seconds). Transaminase levels are normal.
The patient is initially treated with fluids, antibiotic prophylaxis, and octreotide. Endoscopy confirms the presence of bleeding esophageal varices, and ligation is performed.