310 Emergency Medicine
elevated bilirubin and liver enzymes. In alcoholic hepatitis, the AST is greater
than the ALT by a factor of 2. Spider angiomata, palmar erythema, and gyneco-
mastia further suggest underlying liver disease.
(a)A perforated gastric ulcer typically presents with severe sudden
abdominal pain in a patient with a history of PUD. (b)Diverticulosis results
from saclike herniations in the colonic mucosa (diverticula) that occur at
weak points in the bowel wall, usually where arteries insert. Diverticulosis is
most commonly associated with painless rectal bleeding. (c)Splenic laceration
generally results from trauma. (e)The most common symptom with rup-
ture of an AAA is sudden and severe abdominal pain. Back pain, also sud-
den and severe, is noted by half of patients. Incidence of AAA increases
with age in both men and women, and is typically associated with a history
of hypertension.
281.The answer is a.(Tierney et al, 45 ed.)Acute GI bleeding develops
in less than one-third of patients with portal hypertension and varices.
With upper GI bleeds, the initial step is assessment of the hemodynamic
status.Hypotensionwith or without tachycardia identifies a high-risk
patientwith severe acute bleeding. This patient requires immediate treatment.
If initial resuscitative efforts fail or if a patient remains hypotensive, more
aggressive measures may be required, including consideration of Sengstaken-
Blakemore tube placement to physically tamponade the bleeding source,
but this is not part of the initial management and has been associated with
adverse reactions.
(b)In patients with significant bleeding, two 18-gauge or larger IV lines
should be started prior to further diagnostic tests. Blood is sent for CBC,
coagulation studies (prothrombin time [PT] with international normalized
ratio [INR]), serum creatinine, liver enzymes, and cross-matching for 2 to
4 units or more of packed red blood cells (RBC). Patients with hemodynamic
compromise should be resuscitated with crystalloid solutions and cross-
matched blood. Cardiac monitoring and supplemental oxygen should also
be instituted. (c)A NG tube should be placed in all patients with suspected
upper GI bleeding. The aspiration of red blood or “coffee grounds” confirms
an upper GI bleeding source, although 10% of patients with confirmed upper
GI bleeding have nonbloody aspirates, especially when bleeding originates in
the duodenum. An aspirate of bright red blood indicates active bleeding and
is associated with the highest risk of bleeding and complications. Efforts to
control bleeding by gastric lavage with large volumes of fluid are of no benefit
and increase the risk of aspiration. (d)Octreotide reduces splanchnic blood