The most appropriate next step in management is administration of antibiotics. This patient has decompensated cirrhosis as evidenced by previous ascites and jaundice, and she has developed hematemesis, which is most suggestive of a variceal hemorrhage. Patients with cirrhosis, especially those with decompensated cirrhosis, are at high risk for developing bacterial infections during an episode of variceal hemorrhage. A common misperception is that antibiotic prophylaxis need only be provided for patients with variceal hemorrhage and ascites (at risk for spontaneous bacterial peritonitis). A Cochrane systematic review confirmed that antibiotic prophylaxis during variceal bleeding not only helps prevent spontaneous bacterial peritonitis but also helps reduces the risk of bacteremia, pneumonia, and urinary tract infection and reduces mortality. Therefore, prophylactic antibiotics should be provided for patients with cirrhosis and variceal hemorrhage, regardless of the presence or absence of ascites. An oral fluoroquinolone such as norfloxacin or intravenous ciprofloxacin (when oral intake is not possible) are the acceptable choices. Intravenous ceftriaxone may be more effective for patients with Child-Turcotte-Pugh class B and C cirrhosis. The maximum duration of antibiotic administration is 7 days.
A nonselective β-blocker is recommended as secondary prophylaxis after recovery from a variceal bleed, but it would not be warranted in the acute setting in this patient with hypotension.
Evidence regarding the early placement (within 72 hours) of a transjugular intrahepatic portosystemic shunt (TIPS) for patients with variceal hemorrhage is evolving. Despite some evidence of improved mortality for early TIPS placement after endoscopic and pharmacologic control of variceal hemorrhage, this is not the current standard of care. In addition, variceal hemorrhage has not yet been confirmed in this patient, so this intervention is not appropriate at this time.
An upper endoscopy should be performed in this patient with presumed variceal hemorrhage within 12 hours, but only after she has been treated with standard pharmacotherapy (octreotide and antibiotics) and appropriately resuscitated to enable safe endoscopy. A blood pressure of 72/54 mm Hg is too low to be able to proceed immediately with a safe endoscopy.