Acute Upper GI Bleed:

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Acute Upper GI Bleed
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Case 1

• 64/C/M presented to the AE with c/o SOBOE,
  giddiness and lethargy.
• He gives a history of passing out black tarry
  stools yesterday.
• He has been taking diclofenac sodium regularly
  due to bilateral knee pains.
• He has also drinking alcohol regularly, i.e. 2
  large bottle of beers daily.

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• How important are the colour of his stools?

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• What are the possible causes of his GI bleed?

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• What other physical signs are helpful to
  determine the cause of GI bleed?

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Physical examination

• The patient was found to be drowsy, with M5V3E3
  (GCS 11/15)
• BP was 95/70 mm Hg
• HR 110 bpm
• Peripheries was cold and clammy
• Pulse was feeble
• SpO2 95

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• What is the causes of the low GCS?
• What is the significance of the vital signs
  recorded?

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• You find that he has 8 spider naevis, absence of
  axillary hair and gross ascites.
• He has a flapping tremor.
• He also has multiple bruising over the extensor
  surfaces of his arms.

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• What could be the other cause of his low GCS?
• State the stages of hepatic encephalopathy.

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• Suddenly, he develops haemataemesis.
• Do you insert a Ryles tube? State your reasons
  for doing so.

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• You check the vital signs again
• BP 84/50 mm Hg
• HR 150 bpm
• GCS M3V2E1 (6/15)
• SpO2 89

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• Why has the vital signs worsened?
• Why has he become more hypoxic?

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• What do you do now?
• List down your approach to stabilizing this
  patient.

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Investigation results

• TWC 13.5
• Hb 6.0
• MCV 80
• MCH 30
• Plt 500
• Explain the results above.
• Would you expect hypochromic microcytic anemia?

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• APTT 40
• PT 15
• INR 1.8
• What are the possible causes?

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• What other tests to order to elucidate the cause?

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• Urea 28
• Creat 140
• Na 130
• K 3.7
• Explain the results above.

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• TP 60, alb 23
• ALT 878
• ALP 30
• Explain the results.

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• RBS 3.0
• Why?

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• What blood products do you want to give and why?
• What is the target Hb in this patient?

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• List all the problems / diagnosis of this
  patient.

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• What is the definitive treatment of this patient?
• Are there any drugs which helps reduce bleeding?

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• Are antibiotics needed in this patient?

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• What is the follow up care for this patient?

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Case 2

• 60 year old man presents with 1 week history of
  malaena and shortness of breath?
• On examination he his pale and cachexic.
• Hb 9.0g/dL MCV 60 MCH28
• PR showed malaena, examination of the abdomen was
  unremarkable.
• BP 120/80 mm Hg
• HR 99 bpm

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• What could be the possible causes of his UGIB?
• What investigations would you send?

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• Would you transfuse him with blood?
• What are the indications for blood transfusion?
• How fast would you transfuse the blood?
• Do you need to give IV Frusemide as well?

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• OGDS showed a Forrest IIc ulcer.
• What does this mean?

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• How can the ulcer be treated endoscopically?
• What drugs should the patient be given?

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• Patient asks you what are the risks for OGDS.
  What do you say?