Acute Upper GI Bleed: Case 1 64/C/M presented to the A&E 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. How important are the colour of his stools? What are the possible causes of his GI bleed? What other physical signs are helpful to determine the cause of GI bleed? 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% What is the causes of the low GCS? What is the significance of the vital signs recorded? 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. What could be the other cause of his low GCS? State the stages of hepatic encephalopathy. Suddenly, he develops haemataemesis. Do you insert a Ryle’s tube? State your reasons for doing so. You check the vital signs again : – – – – BP 84/50 mm Hg HR 150 bpm GCS M3V2E1 (6/15) SpO2 89% Why has the vital signs worsened? Why has he become more hypoxic? What do you do now? List down your approach to stabilizing this patient. Investigation results TWC 13.5 Hb 6.0 MCV 80 MCH 30 Plt 500 Explain the results above. Would you expect hypochromic microcytic anemia? APTT 40 PT 15 INR 1.8 What are the possible causes? What other tests to order to elucidate the cause? Urea 28 Creat 140 Na 130 K 3.7 Explain the results above. TP 60, alb 23 ALT 878 ALP 30 Explain the results. RBS 3.0 Why? What blood products do you want to give and why? What is the target Hb in this patient? List all the problems / diagnosis of this patient. What is the definitive treatment of this patient? Are there any drugs which helps reduce bleeding? Are antibiotics needed in this patient? What is the follow up care for this patient? 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 What could be the possible causes of his UGIB? What investigations would you send? 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? OGDS showed a Forrest IIc ulcer. What does this mean? How can the ulcer be treated endoscopically? What drugs should the patient be given? Patient asks you what are the risks for OGDS. What do you say?