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Upper gastrointestinal bleeding — USMLE Step 3 MCQ

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HardEmergency MedicineUpper gastrointestinal bleedingUSMLE Step 3

A 58-year-old man with decompensated cirrhosis presents with hematemesis, blood pressure 104/66 mm Hg, and heart rate 108/min after initial crystalloid resuscitation. Hemoglobin is 8.4 g/dL. Large esophageal varices were documented 6 months ago. Endoscopy can occur in 4 hours. Which pre-endoscopic regimen is most appropriate?

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Correct answer: B — Begin intravenous octreotide and ceftriaxone while arranging endoscopy within 12 hours

The best answer is “Begin intravenous octreotide and ceftriaxone while arranging endoscopy within 12 hours”. When variceal bleeding is suspected, vasoactive therapy and short-course antibacterial prophylaxis begin immediately, not after endoscopy. Endoscopy follows resuscitation, generally within 12 hours. Overtransfusion can increase portal pressure, and nonselective beta blockade is not initiated during active hemorrhage.

Reference: AASLD Practice Guidance: Portal Hypertension and Varices in Cirrhosis: https://www.aasld.org/practice-guidelines/portal-hypertension-bleeding-cirrhosis