A 34-year-old man presents to the emergency department(ED) with intermittent melena of 3 days’ duration. He is mildly fatigued but hemodynamically stable and denies any hematemesis or coffee ground emesis. His serum hemoglobin level is 8.2 g/dL. Intravenous (IV) fluids are started. Physical examination is essentially unremarkable. What is the next best step in this patient’s evaluation?
B. Perform a colonoscopy
C. Perform an esophagogastroduodenoscopy(EGD)
D. Start a histamine2 receptor antagonist (H2 blocker)
E. Transfuse 2 U of packed red blood cells
Answer:
(C) Perform an EGD. The patient has melena, which suggests GI bleeding from a source proximal to the ligament of Treitz. Based on the patient’s serum hemoglobin level, he has likely lost significant blood over the past several days and needs to be evaluated for the presence of a bleeding ulcer or other causes of upper GI bleeding. EGD allows for definitive endoscopic evaluation of the esophagus, stomach, and proximal duodenum. Any ulcers identified that warrant endoscopic therapy (eg, cauterization, clipping) could be treated at that time. H. pylori infection could also be assessed via gastric biopsy during the EGD. Serum H. pylori testing would be helpful, but this takes time and the patient needs endoscopy first and foremost to identify the source of the bleeding. The patient does not need blood transfusion at this time given that he is hemodynamically stable. H2 blockers would be inadequate for a patient with a suspected bleeding ulcer. Colonoscopy is unlikely to identify the source of bleeding in a patient with melena.
References: Douglas G. Adler. Peptic Ulcer Disease: Review Questions. Hospital Physician. January 2009;33-35
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