Question 2

Correct answer: A. Intravenous proton pump inhibitor drip. 
 
Rationale  
It is important to understand the initial management of patients with bleeding esophageal varices. With voluminous hematemesis, especially from a proximal source like the esophagus, airway protection is crucial so this patient should be intubated. Patients like this are at high risk to develop infected ascites so IV antibiotics should be given. Antibiotics have been shown to decrease mortality in cirrhotic patients admitted with GI bleeding. Somatostatin analogs decrease portal inflow by causing splanchnic vasoconstriction and have been proven to achieve hemostasis and decrease the risk of rebleeding. One has to be cautious with resuscitation efforts, as excessive resuscitation can lead to accelerated bleeding due to increased portal pressures. However, this patient's Hemoglobin concentration is well below the threshold that warrants transfusion, so giving him PRBCs is appropriate. In the acute setting of an upper GI bleed, proton pump inhibitors work to help optimize platelet function by increasing gastric pH. Since the source here is varices in the more pH neutral esophageal environment, intravenous PPI likely has little effect in the acute setting. However after band ligation is performed, it may help decrease the risk of forming post-banding ulcers. Since this patient's banding was performed a month ago, this episode of bleeding is more likely to be from recurrent varices than from a post-banding ulcer.  
 
References  
Garcia-Tsao G et al. Hepatology. 2007 Sep;46(3):922-38.  
Tripathi D et al. Gut. 2015 Nov;64(11):1680-704.

Correct answer: A. Intravenous proton pump inhibitor drip. 
 
Rationale  
It is important to understand the initial management of patients with bleeding esophageal varices. With voluminous hematemesis, especially from a proximal source like the esophagus, airway protection is crucial so this patient should be intubated. Patients like this are at high risk to develop infected ascites so IV antibiotics should be given. Antibiotics have been shown to decrease mortality in cirrhotic patients admitted with GI bleeding. Somatostatin analogs decrease portal inflow by causing splanchnic vasoconstriction and have been proven to achieve hemostasis and decrease the risk of rebleeding. One has to be cautious with resuscitation efforts, as excessive resuscitation can lead to accelerated bleeding due to increased portal pressures. However, this patient's Hemoglobin concentration is well below the threshold that warrants transfusion, so giving him PRBCs is appropriate. In the acute setting of an upper GI bleed, proton pump inhibitors work to help optimize platelet function by increasing gastric pH. Since the source here is varices in the more pH neutral esophageal environment, intravenous PPI likely has little effect in the acute setting. However after band ligation is performed, it may help decrease the risk of forming post-banding ulcers. Since this patient's banding was performed a month ago, this episode of bleeding is more likely to be from recurrent varices than from a post-banding ulcer.  
 
References  
Garcia-Tsao G et al. Hepatology. 2007 Sep;46(3):922-38.  
Tripathi D et al. Gut. 2015 Nov;64(11):1680-704.

Correct answer: A. Intravenous proton pump inhibitor drip. 
 
Rationale  
It is important to understand the initial management of patients with bleeding esophageal varices. With voluminous hematemesis, especially from a proximal source like the esophagus, airway protection is crucial so this patient should be intubated. Patients like this are at high risk to develop infected ascites so IV antibiotics should be given. Antibiotics have been shown to decrease mortality in cirrhotic patients admitted with GI bleeding. Somatostatin analogs decrease portal inflow by causing splanchnic vasoconstriction and have been proven to achieve hemostasis and decrease the risk of rebleeding. One has to be cautious with resuscitation efforts, as excessive resuscitation can lead to accelerated bleeding due to increased portal pressures. However, this patient's Hemoglobin concentration is well below the threshold that warrants transfusion, so giving him PRBCs is appropriate. In the acute setting of an upper GI bleed, proton pump inhibitors work to help optimize platelet function by increasing gastric pH. Since the source here is varices in the more pH neutral esophageal environment, intravenous PPI likely has little effect in the acute setting. However after band ligation is performed, it may help decrease the risk of forming post-banding ulcers. Since this patient's banding was performed a month ago, this episode of bleeding is more likely to be from recurrent varices than from a post-banding ulcer.  
 
References  
Garcia-Tsao G et al. Hepatology. 2007 Sep;46(3):922-38.  
Tripathi D et al. Gut. 2015 Nov;64(11):1680-704.