Clinical Case:

• Mr Veri Pushi: 

• 45 year old married self-employed property developer

• You are present in casualty when this gentleman is brought in by ambulance at 2 am in the morning.

Clinical Case (2):

• You obtain a quick history from the ambulance officers, and then from his wife (who arrives shortly afterwards by car).

• His wife had found him collapsed in the toilet, confused and very pale.

• He had been complaining of abdominal discomfort just prior to the collapse, had vomited up some altered blood and passed some blackish-red diarrhoea.

Clinical Case (3):

• He had been celebrating the evening before with business associates after concluding the sale of one of his new retirement home developments.

• A considerable amount of alcohol had been drunk by the gentleman that evening and he had felt ‘rough’ when he arrived home 2 hours previously.

• His usual alcohol consumption is around 40-50 units of alcohol per week; he has been drinking at this level for the last 25 years.

Questions:

• What is likely to have occurred with this gentleman?

• What is the differential diagnosis?

• What are your management priorities?

Differential Diagnosis:

• Bleeding peptic ulcer:– Gastric / duodenal

• Bleeding oesophageal varices

• Mallory-Weiss syndrome (Oesophageal Tear)

• Haemorrhagic alcoholic gastritis

• Gastric neoplasm eroded bleeding vessel.

Management Priorities

• Good venous access.• Quick assessment of bleed severity.• Adequate blood samples• Resuscitation of hypovolaemia and

hypotension.• Assessment of rebleeding risk:

– Elderly / hypotensive on admission– Hb < 8 or H&M on admission

Important features to elicit from History & Examination:

• Features of hypovolaemia: pale, sweaty, pulse rate, BP.

• Previous ulcer disease, GI bleeds

• Concomitant medical conditions.

• Anticoagulation therapy.

• Previous or current liver disease, or risk factors for its development (alcohol, parenteral blood products, IV drug abuse etc).

• Stigmata of chronic liver disease.

• History suggestive of Mallory-Weiss tear?

Investigations:• Laboratory:

– FBC– Group & save / Xmatch (see below)– Clotting profile – If on anticoagulants, liver disease,

platelets abnormal, multiple transfusions– U&Es, LFTs

• CXR:– When clinically indicated – – Cardiorespiratory disease / partial gastric volvulus

• ECC:– when clinically indicated.

His vital signs on admission were:

• BP 90 /50 mm Hg lying – unrecordable sitting.

• Pulse 130/min sinus tachycardia

• Respiratory rate 25/min

• Temperature 37.1 C

• JVP not detectable.

Patient stabilisation:

• Large bore cannulas inserted – blood taken.• Resuscitation with volume expanders until

blood is available “Haemaccel / Gelofusin” • Packed red cells – used in conjunction.• If hypotensive on admission – obtain

surgical opinion.• Arrange endoscopy – urgency depending on

severity of bleed and local logistics.

Blood cross-match:

• 1 unit of blood for every 1g/dl that admission Hb below 10g/dL.

• PLUS: – 4 units if patient is shocked on admission.

• PLUS: – 2 units in reserve for a rebleed.

Monitoring management:

• BP & Pulse stabilised with resuscitation.

• Looking for rebleeding signs:– Fresh haematemesis / malaena in stabilised pt– Fall in BP rise in pulse in stabilised pt.– Fall in Hb of > 2g/dl in 24 hours

Unable to stabilise patient:

Seek senior advice.

Consider the need for repeat endoscopy

Consider surgical intervention:

Continued bleeding – esp spurting vessel.

Rebleeding in hospital:

1 rebleed if > 60 years2 rebleeds if < 60 years

High transfusion requirement:

Age > 50 years 4 units

Age < 50 years 6 units