Upper Gastro Intestinal

Bleeding
Seminar 6
Hepatobiliary group B

Mr. 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
Upon
further
up
with his usual
questioning
he schedule because of
fatigability.
states that his
stools are not only
black, but are
sticky and

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.

D ISCU SSIO N
Major clinical problem :
Melena

Suggestive of : Acute GI bleeding

Physicalfi
ndings and lab data support a
diagnosis ofacute bleeding?
Manifestation of hypovolemia.
Anxiety, lightheadedness, restlessness.
Pale, moist skin.
Orthostasis, tachycardia
Weak peripheral pulses

Absorption of blood
Elevated BUN

Loss of blood
Decreased hemoglobin withnormal MCV.
Melena per rectum.

D iff
erentialD iagnosis
Duodenal ulcer
Gastric ulcer
Gastritis (Gastro-duodenal erosions)
Esophagitis (GERD)
Esophageal varices
Mallory-Weiss tear
Arteriovenous malformations
Swallowed blood from hemoptysis or

orpharyngeal bleed

Prioritize steps that w ould likely be taken in

the ER to treat this patient
Brief history/physical exam
Assessing 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.