2. Endoscopy

The patient is relatively stable from a hemodynamic and pulmonary standpoint. Endoscopy is the prime diagnostic and therapeutic tool for upper gastrointestinal bleeding and the procedure of choice (1). Despite this patient’s history of cirrhosis and esophageal varices, bleeding often results from other causes. Administration of octreotide may be useful if she is found to have esophageal variceal bleeding since it lowers portal pressure (1). A recent article comparing a liberal to a conservative transfusion strategy found that mortality was improved if transfusion was not performed until the hemoglobin was below 7 g/dL (2).

The patient’s endoscopy revealed distal esophageal bleeding and varices that were banded (Figure 2).

Figure 2. Images from the patient’s endoscopy showing distal esophageal bleeding (Panel A) and esophageal varices (Panel B).

Her chest x-ray showed low lung volumes and a few nonspecific patchy airspace opacities. There was no further evidence of bleeding or hypotension and the patient was extubated. However, two days later, the patient had respiratory deterioration, failed BiPAP and required reintubation. Chest exam demonstrated only minimal basilar crackles. A repeat chest x-ray is shown in Figure 3.  

Figure 3. Repeat portable chest x-ray taken 2 days after admission.

Which of the following diagnostic or therapeutic strategies should be performed?

  1. Sputum Gram stain and culture
  2. Begin empiric broad-spectrum antibiotic coverage
  3. Begin fluconazole
  4. Administer diuretics
  5. All of the above

Home/Critical Care