hero
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21. A 53-year-old man with a history of recurrent alcoholic pancreatitis develops hematemesis and melena.
On physical examination, pulse rate is 136/min, and blood pressure is 82 mm Hg systolic. Abdominal examination is normal. Hemoglobin is 8.2 g/dL, INR is 1.1, and liver chemistry studies are normal. Nasogastric lavage shows fresh blood.
The patient is stabilized with intravenous fluids and packed red blood cells, following which upper endoscopy is performed. Endoscopic findings include varices of the gastric fundus and cardia and fresh blood in the stomach. No esophageal varices or other sources of bleeding are identified.
Which of the following is most appropriate at this time?
A. Repeat upper endoscopy with banding of varices
B. Transjugular intrahepatic portosystemic shunt (TIPS)
C. Splenectomy
D. Administration of β-blockers
E. Surgical portacaval shunt
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| dr.wad
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A
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| DRamarnath
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b . not A since upperendoscopy already has ruled out esophageal varices
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| telomerase
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A.the most appropriate step at this moment is banding.
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| cool doctor
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D?
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| romano
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cool doctor wrote:
D?
Why? Wouldn't that just lower his blood pressure even more? It's already to low.
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| romano
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DRamarnath wrote:b . not A since upperendoscopy already has ruled out esophageal varices
"Endoscopic findings include varices of the gastric fundus and cardia and fresh..." ?
TIPS is not indicated yet according to emedicine.com: (So I'll go with A)
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accepted indications are as follows:
Acute variceal bleeding that cannot be successfully controlled with medical treatment, including sclerotherapy
Recurrent and refractory variceal bleeding or recurrent variceal bleeding in patients who cannot tolerate conventional medical treatment, including sclerotherapy and pharmacologic therapy
Unproven but promising indications include the following:
Therapy for refractory ascites
Portal decompression in patients with hepatic venous outflow obstruction (Budd-Chiari syndrome), hepatic hydrothorax, or hepatorenal syndrome
Unproven uses include the following:
Initial therapy of acute variceal hemorrhage
Initial therapy to prevent initial or recurrent variceal hemorrhage
Reduction of intraoperative morbidity during liver transplantation
Edited by romano on 01/02/08 - 05:56 AM
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| neurom
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A
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| Ivonne
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Chronic pancreatitis------->gastric varices----------> splenic vein thrombosis?
I just remember that the treatment of gastric varices are a bit different----will check emedicine
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| Ivonne
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Endoscopic injection sclerotherapy and ligation, with interventional radiology as a back -up procedure.
There is no alternative I guess i will go with A
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| sandra
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u r right ivonne..splenic vein thrombosis is a complication of chronic pancreatitis(hypercoaguable state)....i guess its splenectomy..correct me if im wrong.
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| anastamosis
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C.
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| doc_clotaire
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A 
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| anastamosis
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if splenic vein thrombosis is the cause of variceal bleed, SPLENECTOMY is curative.
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| neurom
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anastomosis is right, C should be the answer..
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| hero
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The correct answer is C This patient probably has splenic vein thrombosis that has caused isolated gastric varices. The varices are the source of bleeding. Splenic vein thrombosis occurs in patients with either acute or chronic pancreatitis (more commonly in the latter). Therapy is splenectomy.
In patients with cirrhosis, endoscopic changes include portal hypertensive gastropathy and esophageal varices. Gastric varices may also be seen in these patients. Treatment of portal hypertension includes medical therapy with 3-blockers for primary and secondary prevention of bleeding, endoscopic banding, transjugular intrahepatic portosystemic shunt (TIPS), and surgical portacaval shunt. However, this patient has no evidence of chronic liver disease.
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| Ivonne
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Nice question!!!!
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| neuroblastoma
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i just learn a new concept.
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| cool doctor
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I knew its splenic vein thrombosis but I didnt know what to do for it
Thanks hero, keep up
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