Annals for Educators - 3 December 2019FREE

This guideline updates the 2010 International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding (UGIB).

Cardiovascular disease is the leading cause of death among women in the United States, and stroke is third. This article discusses female-specific cardiovascular risk factors across the lifespan and describes a precision medicine–based approach to risk factor modification and primary prevention, including the current role of genetic testing in the assessment of risk for cardiovascular disease and stroke.

Two cardiologists discuss the U.S. Preventive Services Task Force guidelines on atrial fibrillation and whether they would recommend anticoagulation for a specific patient with screen-detected atrial fibrillation.

Although most U.S. physicians train at Veterans Health Administration hospitals, few have served in the military. The author, a veteran and physician, discusses how failure to appreciate the differences between the civilian and military cultures can result in misalignment of veterans' and physicians' perspectives during management of a veteran's health.

The reality that her partner's liver will fail plunges Dr. Adler into a different side of doctoring.

A 55-year-old man is evaluated after being hospitalized for epigastric pain of 1 month's duration and melenic stools over the past 3 days associated with fatigue. He reports no hematochezia, hematemesis, chest pain, or shortness of breath. He has osteoarthritis treated with ibuprofen. He received an intravenous fluid bolus in the emergency department.

On physical examination, blood pressure is 135/75 mm Hg and other vital signs are normal, with no orthostatic changes. Abdominal examination reveals epigastric tenderness but is otherwise unremarkable. No stigmata of chronic liver disease are seen.

Laboratory studies show a hemoglobin level of 7.3 g/dL (73 g/L).

Upper endoscopy shows a 1.5-cm duodenal bulb ulcer with a clean base.

A. Transfuse red blood cells to a goal hemoglobin level of 8 g/dL (80 g/L)

B. Transfuse red blood cells to a goal hemoglobin level of 9 g/dL (90 g/L)

C. Transfuse red blood cells to a goal hemoglobin level of 10 g/dL (100 g/L)

D. No transfusion

D. No transfusion

Treat upper gastrointestinal bleeding.

This patient does not require transfusion. For patients with upper gastrointestinal bleeding, initial resuscitation is the first priority and should include stabilization of blood pressure with infusion of sufficient volumes of crystalloid fluid and/or red blood cells. The decision to transfuse red blood cells is based mainly on the presenting hemoglobin level. In hemodynamically stable patients, a restrictive transfusion strategy (transfusion threshold of less than 7 g/dL [70 g/L] with a target hemoglobin level of 7-9 g/dL [70-90 g/L]) is associated with decreased mortality, length of hospital stay, and transfusion-related adverse events compared to a liberal transfusion strategy (transfusion threshold of less than 9 g/dL [90 g/L] with a target hemoglobin level of 9-10 g/dL [90-100 g/L]). This patient is hemodynamically and physiologically stable with no evidence of ongoing overt gastrointestinal blood loss or symptoms of tissue ischemia; therefore, it is appropriate to continue maintenance intravenous fluids because he is at an appropriate target hemoglobin level of 7 to 9 g/dL (70-90 g/L).

A modification of the restrictive transfusion threshold may be considered in specific subpopulations, such as patients with hypotension due to severe bleeding and patients with cardiovascular disease. It may be reasonable to give transfusions to patients who are hemodynamically unstable before a decline in hemoglobin level to less than 7 g/dL (70 g/L) to prevent complications of tissue underperfusion. There is uncertainty regarding the need for a higher transfusion threshold in patients with cardiovascular disease, but current guidelines recommend considering transfusion when hemoglobin levels decrease below 8 g/dL (80 g/L) or when cardiovascular symptoms develop (for example, chest pain, dyspnea) in patients who are otherwise hemodynamically stable.

In patients with upper gastrointestinal bleeding, a restrictive transfusion strategy (transfusion threshold of less than 7 g/dL [70 g/L] with a target hemoglobin level of 7-9 g/dL [70-90 g/L]) is associated with decreased mortality, length of hospital stay, and transfusion-related adverse events compared to a liberal transfusion strategy.

Fortinsky KJ, Bardou M, Barkun AN. Role of medical therapy for nonvariceal upper gastrointestinal bleeding. Gastrointest Endosc Clin N Am. 2015;25:463-78. doi:10.1016/j.giec.2015.02.003