How to manage a 40-year-old man with dengue (Dengue Virus Infection) who is Immunoglobulin G (IgG) positive and has a history of passing black stools, indicating possible upper gastrointestinal bleeding?

Management of Dengue Patient with Upper GI Bleeding

A 40-year-old man with dengue IgG positive status who is passing black stools requires immediate resuscitation, hemodynamic stabilization, and urgent endoscopic evaluation to identify and treat the source of upper gastrointestinal bleeding.

Initial Assessment and Resuscitation

Hemodynamic Stabilization

• Place two large-bore IV cannulae (16-18G) in the antecubital fossae 1
• Start with 1-2 liters of normal saline for initial volume replacement 1
• Target hemodynamic parameters:
  • Mean arterial pressure > 65 mmHg
  • Urine output > 30 ml/hour
  • Central venous pressure 5-10 cm H₂O 1

Blood Transfusion Strategy

• Transfuse packed red blood cells when hemoglobin < 7 g/dL (restrictive strategy) 1
• Consider higher transfusion threshold (Hb < 9 g/dL) if patient has:
  • Massive bleeding
  • Significant cardiovascular comorbidities
  • Anticipated delay in therapeutic interventions 1

Coagulopathy Correction

• Check coagulation profile (INR, platelet count)
• Correct coagulopathy if INR > 1.5 or platelets < 50,000/μL 2
• Administer fresh frozen plasma and/or platelets as needed

Diagnostic Approach

Endoscopic Evaluation

• Perform urgent upper endoscopy within 24 hours to identify bleeding source 2, 1
• Digital rectal examination to confirm melena and exclude anorectal pathology 2
• Consider nasogastric tube placement to confirm upper GI source if patient is intubated 2

Additional Investigations

• Complete blood count, liver and renal function tests
• Consider CT angiography if endoscopy is not immediately available or patient is hemodynamically unstable after resuscitation 1

Specific Management

Medical Therapy

• Start high-dose proton pump inhibitor therapy:
  • Omeprazole 80 mg IV bolus followed by 8 mg/hour continuous infusion for 72 hours 1, 3
  • Alternative: pantoprazole 80 mg IV bolus followed by 8 mg/hour continuous infusion 1

Dengue-Specific Considerations

• The patient's IgG positive status indicates secondary dengue infection, which carries higher risk for severe disease 4, 5
• Secondary dengue infections have IgG/IgM ratio ≥ 1.14 in early days of symptoms 5
• Secondary dengue infection is associated with increased risk of hemorrhagic complications 4
• Avoid NSAIDs and other medications that may worsen bleeding risk

Endoscopic Therapy Options

• For bleeding ulcers: combination therapy with injection (epinephrine), thermal coagulation, and mechanical therapy (hemoclips) 1
• For varices: band ligation or sclerotherapy
• Consider endorectal placement of a compression tube as a bridging maneuver if varices are present 2

Post-Endoscopy Care

• Continue IV fluids and PPI therapy
• Monitor vital signs frequently for signs of rebleeding:
  • Fresh melena or hematemesis
  • Fall in blood pressure
  • Rise in pulse rate
  • Fall in central venous pressure 2
• Allow oral intake 4-6 hours after endoscopy if hemodynamically stable 1
• Reintroduce oral PPI therapy when able to tolerate oral medications

Common Pitfalls to Avoid

• Delaying endoscopy in patients with high-risk features can increase mortality 1
• Inadequate initial resuscitation before endoscopic intervention leads to poor outcomes 1
• Neglecting to correct coagulopathy increases rebleeding risk 1
• Overlooking dengue-related thrombocytopenia as a contributing factor to bleeding
• Fluid overload in dengue patients can worsen capillary leak syndrome
• Failure to recognize that up to 8% of lower GI bleeding presentations may have an upper GI source 2