GROUP DMAMBA - MEDENILLA

Case 1: Upper GI Bleeding

Case 1: Upper GI Bleeding

O.L. , 65 y/o, female

Chief complaint• MELENA

History of Present Illness

• 2 episodes of melena (2 cupfuls per episode)• 1 episode of coffee-ground vomiting

•Cold clammy sweats•Dizziness

Past Medical History

Osteoarthritis (5 years ago)• Diclofenac Na intermittently

Last intake: 1 week PTA

(+) Hypertension, diabetes for 15 years

Medications Losartan, metformin/sitagliptin (Janumet),

clopidogrel, simvastatin

Physical Examination

• Vital signs:– BP 120/80 (supine), 100/60 (sitting)– PR 105/min– RR 22/min– Temperature: 37.2°C

• Weight: 68 kg• Height: 160 cm

Physical Examination

Passage of black, tarry, and foul-smelling stools

Caused by a delivery of at least 50 mL of blood into the upper gastrointestinal tract

Degradation of blood to hematin or other hemochromes by bacteria

Blood has been present in the GI tract for at least 14 hours

Chief Complaint:MELENA

Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, 8th ed.Harrison’s Principles of Internal Medicine, 17th ed.

APPROACH TO THE PATIENT:Gastrointestinal Bleeding

APPROACH TO THE PATIENT:Gastrointestinal Bleeding

Immediate assessmentStabilization of hemodynamic statusDetermine the source of bleedingStop active bleedingTreat underlying abnormalityPrevent recurrent bleeding

APPROACH TO THE PATIENT:Gastrointestinal Bleeding

Immediate assessment Heart rate Blood pressure

Patient’s Hemodynamic Status (Vital Signs)

Blood Loss (% of

Intravascular Volume)

Severity of Bleed

Shock (resting hypotension) 20-25 Massive

Postural (orthostatic hypotension and tachycardia)

10-20 Moderate

Normal <10 MinorSleisenger and Fordtran’s Gastrointestinal and Liver Disease, 8th ed.

APPROACH TO THE PATIENT:Gastrointestinal Bleeding

Resuscitation Restore and maintain normal vital signs

History and physical examination Preliminary assessment of the site and cause

Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, 8th ed.

APPROACH TO THE PATIENT:Gastrointestinal Bleeding

Differentiation of upper from lower GIBUpper GIB Lower GIB

Hematemesis Hematochezia

Melena

Hematochezia

Hyperactive bowel sounds

Elevated BUN

Harrison’s Principles of Internal Medicine, 17th ed.

APPROACH TO THE PATIENT:Gastrointestinal Bleeding

Differentiation of upper from lower GIB

Patient Melena, hematemesis, and hyperactive bowel

sounds

Upper GIB Lower GIB

Hematemesis Hematochezia

Melena

Hematochezia

Hyperactive bowel sounds

Elevated BUN

Harrison’s Principles of Internal Medicine, 17th ed.

APPROACH TO THE PATIENT:Gastrointestinal Bleeding

Differentiation of upper from lower GIB

Patient Melena, hematemesis, and hyperactive bowel

sounds

Upper GIB Lower GIB

Hematemesis Hematochezia

Melena

Hematochezia

Hyperactive bowel sounds

Elevated BUN

Harrison’s Principles of Internal Medicine, 17th ed.