Vignette: A 69-year-old African American man comes to the ED with concerns of altered mental status and vomiting blood.

Medical History: Atrial fibrillation, hypertension, cirrhosis, congestive heart failure (CHF), coronary artery disease, hyperlipidemia, peptic ulcer disease, and esophageal varices

Social History: Unknown

Current Medications: Home medications include aspirin 81 mg once daily, amlodipine 10 mg once daily, clopidogrel 75 mg once daily, furosemide 80 mg once daily, lisinopril 20 mg once daily, nadolol 40 mg once daily, rosuvastatin 20 mg once daily at bedtime, and warfarin 7.5 mg once daily at bedtime.

Allergies: No known drug allergies

Vital Signs: BP 68/44 mm Hg, HR 114 beats/minute, RR 24 breaths/minute, Spo₂ 92% on room air

Laboratory Values: Na 133 mEq/L (133 mmol/L), K 4.5 mEq/L (4.5 mmol/L), Cl 98 mEq/L (98 mmol/L), glucose 145 mg/dL (2.4975 mmol/L), SCr 1.5 mg/dL (132.6 µmol/L), total bilirubin 5 mg/dL (85.5 µmol/L), INR 9.6, Plt 55,000/mm³ (55 × 10⁹/L), Hgb 5.1 g/dL (51.0 g/L), Hct 16% (0.16)

Question 1

The patient’s vomit is described as dark brown by the nursing staff as the patient continues to have bouts of emesis. Which therapy would be best to recommend in conjunction with antiemetic therapy?

1. Famotidine 40 mg intravenously
2. Pantoprazole 40 mg intravenously
3. Ranitidine 50 mg intravenously
4. Lansoprazole 30-mg orally disintegrating tablet

Answer: 2. Pantoprazole 40 mg intravenously

Rationale: Pantoprazole 40 mg intravenously is correct because the patient has peptic ulcer disease. Ranitidine and famotidine are incorrect because histamine-2 receptor antagonists have not been shown effective in preventing rebleeding episodes. Oral lansoprazole is incorrect because the patient is actively vomiting.

Citations:

1. Barkun AN, Almadi M, Kuipers EJ, et al. Management of nonvariceal upper gastrointestinal bleeding: guideline recommendations from the International Consensus Group. Ann Intern Med 2019;171:805-22.

2. Tripathi D, Stanley AJ, Hayes PC, et al. UK guidelines on the management of variceal hemorrhage in cirrhotic patients. Gut 2015;64:1680-704.

Question 2

The patient has abdominal pain and a temperature of 102.7°F (39.3°C). Which of the following would be the best treatment to add (in addition to antibiotics) for spontaneous bacterial peritonitis (SBP) that has been shown to decrease the risk of renal failure and death?

1. Albumin 25%
2. Dextrose 5% in water
3. Lactated Ringer solution
4. Normal saline

Answer: 1. Albumin 25%

Rationale: The patient has a fever and abdominal pain, making clinical suspicion high for SBP, given his history of cirrhosis. Albumin 25% is preferred as a resuscitative fluid in SBP because it has been shown to reduce rates of acute kidney injury in patients with SCr greater than 1 mg/dL or total bilirubin greater than 4 mg/dL. Normal saline, dextrose 5% in water, and lactated Ringer solution are not the best choices, given the reduction in mortality rates with albumin.

Citations:

1. Sort P, Navasa M, Arroyo V, et al. Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med 1999;341:403-9.

2. Abd Elaal MM, Zaghloul SG, Bakr HG, et al. Evaluation of different therapeutic approaches for spontaneous bacterial peritonitis. Arab J Gastroenterol 2012;13:65-70.

Question 3

Which therapy would be best to recommend to the ED provider for an acute variceal GI bleed?

1. Angiotensin II
2. Norepinephrine
3. Octreotide
4. Terlipressin

Answer: 3. Octreotide

Rationale: Octreotide, a somatostatin analog, together with somatostatin has been associated with decreased 7-day mortality and rebleeding. Terlipressin is unavailable in the United States; otherwise, it would be an agent for consideration. Norepinephrine and angiotensin II have not been studied in variceal GI bleeds or shown to have benefit in this patient population.

Citation: Wells M, Chande N, Adams P, et al. Meta-analysis: vasoactive medications for the management of acute variceal bleeds. Aliment Pharmacol Ther 2012;35;1267-78.

Question 4

The patient is taken for a head CT scan because of altered mental status, and it discovered that he has a subdural hematoma. The team wants to treat the elevated INR and reverse the patient’s anticoagulation. Which treatment would be best to recommend?

1. Andexanet alfa 800-mg intravenous bolus followed by an 8-mg/minute infusion
2. Vitamin K 10 mg intravenously
3. Vitamin K 10 mg intravenously plus 2 units of fresh frozen plasma intravenously
4. Vitamin K 10 mg intravenously plus prothrombin complex concentrate (PCC) 50 units/kg intravenously

Answer: 4. Vitamin K 10 mg intravenously plus PCC 50 units/kg intravenously

Rationale: Intravenous vitamin K monotherapy is insufficient to emergently reverse anticoagulation. Fresh frozen plasma cannot be used because the patient has CHF. Andexanet alfa is incorrect because this is an antidote for factor Xa inhibitors and not warfarin.

Citations:

1. Frontera JA, Lewin JJ, Rabinstein AA, et al. Guideline for reversal of antithrombotics in intracranial hemorrhage. Neurocrit Care 2015;24:6-46.

2. Andexanet alfa. In: Lexicomp Online. Wolters Kluwer, 2020. Available at http://online.lexi.com/. Updated November 22, 2019.

Question 5

The patient has received reversal for anticoagulation and treatment for the acute GI bleed from a presumed variceal source. Which of the following intravenous antibiotics would be best to recommend for initial prophylaxis of SBP?

1. Ceftriaxone 1 g
2. Clindamycin 600 mg
3. Ciprofloxacin 400 mg
4. Metronidazole 500 mg

Answer: 1. Ceftriaxone 1 g

Rationale: Answer 1, intravenous ceftriaxone 1 g, is correct. The patient has no medication allergies, and β-lactams would be preferred to fluoroquinolone antibiotics because of possible resistance to fluoroquinolone use (Answer 3 is incorrect). Neither clindamycin nor metronidazole has adequate coverage of the gram-negative bacteria that cause SBP (Answers 2 and 4 are incorrect).

Citations:

1. Fernandez J, Ruiz del Arbol L, Gomez C, et al. Norfloxacin vs ceftriaxone in the prophylaxis of infections in patients with advanced cirrhosis and hemorrhage. Gastroenterology 2006;131:1049-56.

2. Cavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila F, et al. Meta-analysis: antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding – an updated Cochrane review. Aliment Pharmacol Ther 2011;34:509