Kamsi
Forum Guru
Topics: 103
Posts: 347
|
A 46 -year -old male comes to the emergency room because of hematemesis, which started one hour ago. His vital
signs are, PR: 90/min; BP: 120/70mm of Hg; RR: 14/min; Temperature: 36.6C(97.9F). He has had chronic hepatitis
B, for 12 years. The patient is oriented, but somewhat sleepy, and a flapping tremor is noted. Abdomen is soft, -
tender, and non -distended. Liver and spleen are palpated 2cm and 4cm below the costal line, respectively. Shifting
dullness is present. Nasogastric tube revealed bright red blood that was easily cleared with cold saline lavage.
Endoscopy shows a fresh ulcer with a small adherent clot located high on the lesser curvature near the
gastroesophageal junction. Esophageal and gastric varices are also clearly seen.
His laboratory results are:
Hb 12.0
WBC 3,200cmm
PT 15
PTT 37
AST 14
ALT 9
Bilirubin total/direct 2.2/0.3 mg/dL
Albumin 3.1
What will be the most appropriate next step in the management of this patient?
A. Sclerotherapy of the varices
B. Porto -systemic shunt
C. Esophageal and proximal gastric devascularisation, splenectomy, selective vagotomy and pyloroplasty
D. Excision of the ulcer, selective vagotomy and pyloroplasty
E. Conservative management
|
| docfor99
Forum Senior
Topics: 10
Posts: 110
|
E ?
|
| sukhs
Forum Senior
Topics: 17
Posts: 191
|
B 
|
| Justice
Forum Fanatic
Topics: 117
Posts: 2,323
|
E. Conservative management
the Pt has signs of metabolic intoxication due to hepatic failure... Any intervention should be done after the above is corrected
___________________
Don't live in a town where there are no doctors
|
| dermatology
Forum Elite
Topics: 30
Posts: 297
|
why not A ???? patient got ulcer which is cover with tiny clot for now close to GE junction .... this ulcer can start bleeding anytime and irritate esophageal varices and cause massive bleeding ...which can b prevented by sclerotherapy ...
its just a thought i dont know exact answer
|
| xenab
Forum Newbie
Topics: 1
Posts: 6
|
well from my point of vies this question is a "gimme".the answer is E
how?lets look at the choices.
A. varices are only treated with sclerotherpy wen bleeding .otherwise we go for a conservative management to decrease portal htn ideally with octreotide.
B.the pt. has hepatic encephalopathy which is WORSENED by a portocaval shunt so this choice is out.
C.this choice is out bcz it has splenectomy in it and the first rule with spleen is PRESERVATION under all costs.
D.now this is the trap choice .....the rule is not to perform surgery witha first time ulcer but control it with conservative medical management.recurrent ulcers NOT responding to medical Rx need surgery of any kind.
|
| Doc750
transfer:step 3 prison
Topics: 52
Posts: 634
|
E
___________________
Experience is a hard teacher because she gives the test first, and the lesson afterwards.
|
| Ivonne
Find a way or make one
Topics: 57
Posts: 1,602
|
(E)
___________________
92/99/pass/ECFMG certified/4 US LoRs/GC/extensive USCE/2004 grad/appl 29 IM Prog, IV/Rej: 3/0 "I must, I can and I will"
|
| kpmle2
Forum Elite
Topics: 60
Posts: 381
|
E. Conservative management
|
| Dr.D
Forum Senior
Topics: 22
Posts: 191
|
E
|
|
| |
| | | | | | | | | | |
