Upper GI bleeding

You are asked to evaluate and treat a patient with hematemesis. He is 34 years old, has no chronic medical illnesses, and presents with syncope soon after vomiting bright-red blood. In the emergency department, red hematemesis is documented. On examination, he is awake but agitated, with cool extremities and dry mucous membranes. His heart rate is 130 beats per minute and his supine blood pressure is 90/60 mm Hg. There is no scleral icterus. The abdomen is soft and nontender without hepatomegaly, with black stool in the rectum that is flash positive for occult blood. Laboratory studies reveal a hemoglobin level of 11.0, BUN/creatinine levels of 40/0.9, normal prothrombin time/partial thromboplastin time, aspartate aminotransferase/alanine aminotransferase levels of 119/42, alcohol level of 280. What should be the first intervention for this patient?

1- Bolus and infusion of octreotide

2- Bolus and infusion of a PPI

3- Insertion of a nasogastric tube

4- Emergent upper endoscopy

5- Placement of large-bore intravenous lines for vigorous fluid resuscitation

During an endoscopy, active bleeding begins. What is the best course of treatment at this point?

1- Bolus and infusion of a proton pump inhibitor (PPI)

2- Epinephrine injection

3- Argon plasma coagulation

4- Contact thermal therapy (heater probe or multipolar electrocautery) or placement of NGT

5- Combination therapy with B and D

After endoscopic therapy, the bleeding stops and the patient stabilizes. He requires 3 units of packed erythrocytes to maintain a hemoglobin level at more than 10 g/dL. Three days later, on a clear liquid diet and taking a PPI twice daily, melena develops. His pulse increases to 100 beats per minute, but no orthostasis is noted. The hemoglobin level drops to 9 g/dL. What is the next best step?

1- Consult surgery for a definitive antiulcer operation.

2- Consult surgery for vagotomy and oversewing of the bleeding vessel

3- Consult surgery to oversew the bleeding vessel.

4- Repeat OGD for possible endoscopic therapy.

5- Transfuse packed red blood cells and observe.

At urgent endoscopy, no active bleeding or old blood is seen. A few erosions are noted in the gastric antrum. Inspection of the duodenal bulb reveals a raised red protuberance in the center of an ulcer. The duodenal ulcer measures 15 mm in diameter. What is the approximate likelihood of rebleeding from this ulcer?

1- < 10%

2- 20 %

3- 40 %

4- 80 %