What is the best next step in managing a 65-year-old man with a history of cirrhosis (liver disease) and esophageal varices (enlarged veins in the esophagus) who presents with a resolved episode of hematemesis (vomiting blood)?

From the Guidelines

The best next step in the care of this 65-year-old man with cirrhosis and esophageal varices who presented with hematemesis is to treat for a variceal bleed and admit him to the hospital. Despite the patient's stable vital signs and his perception that the bleeding has stopped, hematemesis in a cirrhotic patient with known varices represents a potentially life-threatening emergency that requires immediate intervention. The mortality rate for variceal bleeding is significant, and rebleeding can occur unpredictably, as noted in the study by 1. Initial management should include securing intravenous access with two large-bore IVs, fluid resuscitation, blood typing and cross-matching, and starting prophylactic antibiotics such as ceftriaxone 1g IV daily, as recommended by 1. Pharmacologic therapy with octreotide (50-100 mcg IV bolus followed by 25-50 mcg/hour infusion) should be initiated to reduce portal pressure, as suggested by 1. Endoscopic evaluation within 12-24 hours is essential for definitive diagnosis and treatment, which may include band ligation or sclerotherapy of the bleeding varices, as stated in 1. Even though the previous endoscopy showed only small varices, varices can enlarge over time, and even small varices can cause significant bleeding in the setting of coagulopathy from cirrhosis. Some key points to consider in the management of this patient include:

• The importance of early endoscopy to diagnose and treat variceal bleeding, as emphasized by 1
• The use of vasoactive agents, such as octreotide, to reduce portal pressure, as recommended by 1
• The need for prophylactic antibiotics to prevent infections, as suggested by 1
• The importance of monitoring for complications, such as rebleeding and hepatic encephalopathy, as noted in 1. Overall, the management of this patient should prioritize reducing the risk of rebleeding, managing complications, and improving quality of life, as emphasized by the studies 1.

From the Research

Patient Assessment and Management

The patient presents with a history of cirrhosis and esophageal varices, and has experienced a brief episode of hematemesis. Given the patient's medical history and current presentation, it is essential to consider the risk of variceal bleeding and the need for prompt treatment.

Treatment Options

• The patient requires immediate attention to prevent further bleeding and complications.
• According to 2, the first step in bleeding control is hemodynamic stabilization and pharmacological treatment, which includes administration of vasoactive drugs and short-term antibiotic prophylaxis.
• Endoscopic therapy, such as endoscopic variceal ligation (EVL) or endoscopic injection sclerotherapy (EIS), should be performed after initial hemodynamic stabilization 2, 3.
• The patient's vital signs are currently within normal limits, but this does not rule out the risk of rebleeding.

Next Steps

• Given the patient's history of esophageal varices and the current episode of hematemesis, it is crucial to treat for variceal bleed and admit the patient to the hospital for close monitoring and further management 2, 4, 5.
• Discharging the patient without proper treatment and monitoring may put them at risk of further complications and rebleeding.
• Checking INR and considering discharge if normal may not be sufficient, as the patient's condition requires more comprehensive management 6.