Question

A 45-year-old man presents with hematemesis. He has had 2 episodes of vomiting 'coffee-ground'-appearing material; the vomiting began 45 minutes prior to presentation. Additionally, he reports passing black, sticky stools for the past 3 or 4 days. Past medical history is positive for occasional headaches; they have been coming more frequenly lately. Social history reveals alcohol use (1 case of beer each weekend) and tobacco (1 pack per day). Medications include ibuprofen as needed for headaches; he has been taking 800 mg 3 times a day for the past week. You place a nasogastric tube and find bright red blood that fails to clear with saline irrigation. Hemoglobin is 8.9 g/dL. Evaluation of his blood pressure and pulse reveals orthostatic changes that resolve with an intravenous fluid bolus of 500 cc of Lactated Ringer's solution.

What should you do next?

1. Transfuse 2 units of packed red blood cells and recheck CBC in 8 hours
2. Check serum for Helicobacter pylori antibody
3. Order a double contrast barium swallow to evaluate for a gastric ulcer
4. Refer for emergency upper endoscopy
5. Discontinue his ibuprofen use and encourage cessation of alcohol and tobacco

Answer 1

The patient should be referred for 4)an emergency upper endoscopy due to the signs of a significant upper gastrointestinal bleed.

Step-by-step explanation:

The 45-year-old man with a history of hematemesis and melena should be referred for an emergency upper endoscopy. His presentation is suggestive of a significant upper gastrointestinal bleed, which could be due to ulcers, gastritis, or other gastrointestinal pathology.

The use of ibuprofen, particularly at high doses, and his alcohol and tobacco consumption are likely contributing factors to his condition. Discontinuation of ibuprofen and advising cessation of alcohol and tobacco are also essential steps in the management of his condition.

Given the acuity of his presentation and the finding of bright red blood in the nasogastric tube that failed to clear with saline irrigation, alongside orthostatic changes indicating hypovolemia, an urgent endoscopic evaluation is warranted to identify the source of bleeding and to initiate appropriate therapeutic interventions.