Lewis J. Wesselius, MD
Department of Pulmonary Medicine
Mayo Clinic Arizona
Scottsdale, AZ
History of Present Illness
A 66 year old woman presented to outside hospital with hematemesis and hematochezia. She was intubated for airway control and received 4 units of packed red blood cells. She was transferred to the Mayo Clinic Arizona due to an inability to control her upper gastrointestinal bleeding. During her transfer she required vasopressors.
PMH
She has a history of hepatitis C with cirrhosis and esophageal varices. In addition, she was diagnosed with a B-cell lymphoma 3 months prior to admission and had received 3 cycles of rituximab, cyclophosphamide, hydroxydaunorubicin (doxorubicin), Oncovin® (vincristine) and prednisone (R-CHOP).
Physical Examination
She was intubated and receiving oxygen at a FiO2 of 0.4.
Vital signs: P 100 beats/min; B/P 113/78 mm Hg; Afebrile; R 20 breaths/min; SpO2 99%
Chest: clear to auscultation.
Laboratory
Her hemoglobin was 9.3 g/dL and her hematocrit was 29%.
Radiology
Her admission chest x-ray is shown in Figure 1.
Figure 1. Admission portable chest-x-ray.
Which of the following should be done initially?
- Bronchoscopy with bronchoalveolar lavage
- Endoscopy
- Administer octreotide to control hypotension
- Administer 2 units of packed red blood cells to stay ahead of the bleeding
- All of the above
Reference as: Wesselius LJ. May 2013 critical care case of the month: not an air-filled sac. Southwest J Pulm Crit Care. 2013;6(5):209-17. PDF