complete blood cell (CBC) count, platelet count, prothrombin time (PT), and partial thromboplastin time (PTT) Additional laboratory studies may be indicated on the basis of the differential diagnosis of the most likely cause of the patient’s bleeding Arterial blood gases should also be followed when severe blood loss is associated with shock The hematocrit is an unreliable initial index of acute blood loss because it may be normal or only slightly decreased and not accurately reflect the actual value in a rapid bleed TABLE 91.1 CAUSES OF PORTAL HYPERTENSION AND ESOPHAGEAL VARICES Location of lesion Example Prehepatic • Portal vein thrombosis • Portal vein obstruction (i.e., malignancy) • Splenic vein obstruction Intrahepatic • Cirrhosis from biliary atresia, primary sclerosing cholangitis, cystic fibrosis, α1 antitrypsin deficiency, chronic hepatitis B/C, autoimmune hepatitis, chronic alcohol use Posthepatic • Budd–Chiari syndrome: thrombosis or exterior compression (i.e., malignancy) • Inferior vena cava obstruction • Constrictive pericarditis • Increased portal or splenic blood flow • Portal vein sclerosis/venopathy (i.e., schistosomiasis, HIV, cystic fibrosis) • Schistosomiasis • Idiopathic portal hypertension • Congenital hepatic fibrosis • Nonalcoholic fatty liver disease • Congestive heart failure • Venoocclusive disease TABLE 91.2 SIGNS AND SYMPTOMS OF PORTAL HYPERTENSION System Physical examination findings Clinical complications CNS Hematologic Altered mental status Splenomegaly Petechiae/purpura Ecchymosis Pallor Bounding pulses Systolic flow murmur Warm extremities Abdominal distention/ascites Peripheral vasodilation/palmar erythema Edema Venous hum over collateral vessels Hepatomegaly Splenomegaly Nausea/vomiting Melena/hematochezia Hematemesis Abdominal pain/fever Dilated abdominal vasculature Abdominal distention/pain Jaundice Fetor hepaticus (rare in children) Spider angiomas Hepatic encephalopathy Thrombocytopenia Leukopenia Anemia Dyspnea Hypoxemia Hepatopulmonary syndrome Circulatory GI Pulmonary Hypotension Ascites Hepatorenal syndrome Hepatopulmonary syndrome Portopulmonary hypertension Gastroesophageal varices Recta varices Congestive/hemorrhagic gastritis Ascites Spontaneous bacterial peritonitis Renal Digital clubbing Cyanosis Portopulmonary hypertension Edema Abdominal distention/ascites Hepatorenal syndrome Hypervolemia Transfusion of blood products may be necessary to maintain adequate endorgan perfusion with severe GI bleeding The volume of blood products that should be administered as well as the timing of those transfusions is controversial Current recommendations generally target a hemoglobin transfusion goal of to g/dL Excessive blood administration, especially in the setting of non–life-threatening bleeding, should be avoided, as it is known to contribute to rebleeding Coagulation abnormalities should be managed aggressively only if there is active bleeding, as transfusion of blood products may lead to volume overload In patients who are not actively bleeding, the ED physician should not attempt to correct a coagulopathy as a patient’s PT and INR can be very difficult to correct and are not reliable indicators of bleeding risk in those with underlying liver disease It is also important to note that bleeding varices may be the initial sign of sepsis in patients who have cirrhosis Prophylactic broad-spectrum antibiotics, after appropriate cultures are obtained, are recommended in the setting of a significant esophageal bleed