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Chapter 24: Gastroenterology

A 67-year-old man with a history of hypertension, diabetes, and osteoarthritis presents with a 1-day history of black stool. Since his symptoms began, he endorses about 2 to 3 black bowel movements; he notes that there also appears to be a rim of red around the black stool noted on the toilet paper. He began to feel lightheaded and dizzy at home, so he came to the ED. There, he was found to have the following vital signs: BP of 77/46 mmHg, HR of 110 beats/min, RR of 12 breaths/min, oxygen saturation (Sao2) of 99%, and temperature of 36.4°C (97.5°F). His labs included the following:

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WBC 12 × 103/μL
Hgb 5.5 g/dL (baseline: 12 g/dL)
plt 197 × 103/μL
Na 138 mEq/L
K 4.0 mEq/L
Cl 107 mEq/L
CO2 24 mEq/L
BUN 35 mg/dL
Creatinine 1.1 mg/dL

On further questioning, a few days prior to the start of his symptoms he tripped and fell, exacerbating the pain from his osteoarthritis. Resuscitation is begun in the ED, and the patient is admitted to the ICU for further monitoring. In addition to large-bore IV access, NPO status, and blood transfusion, what is the most appropriate next step in management?

A. Nasogastric tube placement

B. Pantoprazole 80 mg IV × 1 with initiation of pantoprazole drip at 8 mg/h

C. Pantoprazole 40 mg IV every 12 hours

D. Pantoprazole 40 mg PO every 12 hours

B. Pantoprazole 80 mg IV × 1 with initiation of pantoprazole drip at 8 mg/h

After appropriate resuscitation with IV fluids and blood products, initial medical therapy should include an IV proton pump inhibitor. Typically, a PPI is initially given as a high-dose bolus followed by a continuous infusion (choice B). Although pre-endoscopic PPI therapy has not been shown to improve mortality or the risk of rebleeding, it does appear to reduce the incidence of finding ulcers with high-risk stigmata of hemorrhage, and therefore reduce the need for endoscopic therapy. Intermittent dosing with an IV PPI (choice C) may be utilized for postendoscopic medical therapy but is not appropriate for pre-endoscopic medical therapy. A PPI should not be given orally prior to endoscopy, as the patient should be NPO; in addition, acid suppression is achieved more rapidly with IV dosing. While nasogastric lavage (choice A) is frequently attempted to document a UGI source of bleeding, a negative NG aspirate does not necessarily rule out an upper GI source; therefore, its utility is limited.

A patient admitted for upper GI bleeding has an endoscopy. A clean-based ulcer ...

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