68-year-old man with hematemesis
A 68-year-old man presents to the emergency department with a single episode of hematemesis. He states he vomited about a cup of bright red blood one hour ago, but has had no further episodes. He feels lightheaded but denies chest pain or shortness of breath. His medical history is notable for an open abdominal aortic aneurysm repair with a synthetic graft placed 8 years ago. He also has hypertension and osteoarthritis. His medications include lisinopril and celecoxib. On examination, temperature is 37.1°C (98.8°F), blood pressure is 112/74 mmHg, pulse is 96/min, and respirations are 16/min. The abdomen is soft, non-tender, with a well-healed midline surgical scar. Rectal examination reveals brown, guaiac-negative stool. Laboratory studies show a hemoglobin of 10.2 g/dL, down from a baseline of 12.8 g/dL six months ago. His platelet count is 190,000/µL and INR is 1.0. Which of the following is the most appropriate next step in management?
See the answer and explanation below:
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B
Explanation
Clinical Pearl:
In any patient with a history of aortic surgery or an aortic graft who presents with gastrointestinal bleeding, aortoenteric fistula must be suspected. Urgent CT angiography is the diagnostic test of choice as endoscopy is often non-diagnostic and can delay life-saving surgery.
Explanation:
This patient's presentation of hematemesis, in the context of a prior abdominal aortic aneurysm repair with a synthetic graft, is highly concerning for a secondary aortoenteric fistula. The most appropriate next step is to obtain a CT angiography of the abdomen and pelvis. This is the most sensitive non-invasive test to diagnose an aortoenteric fistula, a surgical emergency with extremely high mortality if missed. While upper endoscopy is standard for most upper GI bleeds, it has low sensitivity for this diagnosis and a negative result can be falsely reassuring, delaying definitive management. Transfusion of packed red blood cells is not indicated at this time, as the patient is hemodynamically stable and his hemoglobin is above the typical transfusion threshold of 7 g/dL. Stopping the NSAID and starting a PPI is appropriate for a suspected peptic ulcer but fails to address the most lethal potential diagnosis first. Nasogastric tube lavage has limited utility and would inappropriately delay necessary diagnostic imaging.
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