Upper Gastro Intestinal Bleeding

Upper Gastro Intestinal BleedingSeminar 6Hepatobiliary group BMr. Murphy is a 45 year old advertising executive who presents to the emergency room complaining of the passage of black stools x 3 days and an associated lightheadedness. He also relates that he cannot keep up with his usual schedule because of fatigability.

Upon further questioning he states that his stools are not only black, but are sticky and malodorous. He further complains of recent worsening of a chronic epigastric burning which had been a problem off/on for years. He had doubled his usual dose of turns without significant relief of the burning. He takes NSAIDS as needed for back pain and recently started on one aspirin per day for cardiac prophylaxis. He smokes two packs of cigarettes per day and an occasional cigar. He was told of an ulcer in the distant past but had no specific evaluation or treatment for same.Mr. Murphy has been treated for hypertension for eight years but not known any cardiac history. His weight is stable to increased and he has an excellent appetite. He has a normal bowel habit and has not had prior black stools. He has had no abdominal surgery and denies bleeding tendencies or prior transfusion.

PHYSICAL EXAMINATION Examination reveals an alert, oriented, overweight male. He appears anxious and somewhat restless. Vital sips are as follows. Blood Pressure 120/80 mmHg, Heart Rate 110/min - Supine;BP 90/60 mmHg; HR Thready - Standing (Patient complains of dizziness upon standing). Respiratory Rate - 20 /minute; Temperature 98 F.HE-ENT/SKIN: Facial pallor and cool, moist skin are noted. No telangiectasia of the lips or oral cavity are noted. No spider nevi are seen. The parotid glands appear full.CHEST: Lungs are clear to auscultation and percussion. The cardiac exam reveals regular rhythm with an S4. No murmur is appreciated. Peripheral pulses are present but are rapid and weak.

ABDOMEN/RECTUM: The abdomen reveals a rounded abdomen. Bowel sounds are hyperactive. There is moderate tenderness in the epigastrium. The liver is percussed to 13 cm (mal); the edge feels firm. The spleen was not felt and no masses were appreciated; the exam was felt to be suboptimal secondary to the patient's obesity. Rectal examination revealed black, tarry stool.There are no dupuytren's contractions.

LABORATORYTESTS:Hemoglobin 9gm/dL, Hematocrit 27%, MCV 90. WBC13,000/mm. PT/PTT - normal. BUN 45mg/dL, Creatinine 1.0 mg/dL. Chest x-ray - normal. X-ray of abdomen (kidney, ureter, bladder - KUB) is unremarkable.

DISCUSSIONMajor clinical problem :Melena

Suggestive of : Acute GI bleedingPhysical findings and lab data support a diagnosis of acute bleeding?

Manifestation of hypovolemia.Anxiety, lightheadedness, restlessness.Pale, moist skin.Orthostasis, tachycardiaWeak peripheral pulsesAbsorption of bloodElevated BUNLoss of bloodDecreased hemoglobin withnormal MCV.Melena per rectum.

Differential DiagnosisDuodenal ulcerGastric ulcerGastritis (Gastro-duodenal erosions)Esophagitis (GERD)Esophageal varicesMallory-Weiss tearArteriovenous malformationsSwallowed blood from hemoptysis or orpharyngeal bleed

Prioritize steps that would likely be taken in the ER to treat this patientBrief history/physical examAssessing the degree of circulatory compromise by doing orthostatics.Establish IV access with 2 large bore IVs.Volume replacement.Type and cross-match for blood.Nasal oxygen.ECG.Laboratory evaluation to include CBC, coags, BUN, creatinine.Nasogastric tube.Consult with endoscopist and surgical colleagues.