Gastrointestinal
Bleeding
Answers
275.The answer is a.(Rosen, p 197.)Emergency medicine always starts
with an assessment of the patient’s airway.For patients suspected of having
a significant GI bleed, two large-bore IV linesneed to be established
rapidly. Treating an undifferentiated upper GI bleed is like treating a gunshot
wound to the abdomen—you should expect the worst. Immediate volume
resuscitation should begin with 1 to 2 L of normal saline. If there is no
improvement in the BP of a hypotensive patient, then blood should be admin-
istered. Sending a cross-match early is advisable since it can take up to an
hour to retrieve. Use type O, Rh-negative (if female) or type O, Rh-positive
(if male) if type-specific blood is not ready. It is crucial to remember that
the initial hematocrit of the patient is a poor indicator of the severity of
acute bleeding because it takes 24 to 72 hours to equilibrate.
(b)A proton-pump inhibitor may be administered but priority is to the
airway, breathing, and circulation (ABCs) and this patient is hypotensive.
(c)You must assess airway first. (d and e)The patient is maintaining his
airway and does not need to be intubated emergently. However, if his BP
worsens and he becomes altered or you anticipate his condition to worse,
then endotracheal intubation is appropriate.
276.The answer is d.(Rosen, pp 1343-1350.)Hemorrhoids are dilated
venules of the hemorrhoidal plexuses. They are associated with constipation,
straining, increased abdominal pressure, pregnancy, increased portal pressure,
and a low-fiber diet. Hemorrhoids can be either internal or external. Those
that arise above the dentate line are internal and painless. Those that are
below the dentate line are external and painful. Individuals commonly
present with thrombosed external hemorrhoids. On examination, there is a
tender mass at the anal orifice that is typically bluish-purple in color. If pain
is severe and the thrombosis is less than 48 hours then the physician should
excise the thrombus under local anesthesia followed by a warm sitz baths.
This patient is suffering from an acutely thrombosed external hemorrhoid.
306