History
A 60-year-old gentleman with a history of osteoarthritis (OA) of the knee presents to the emergency department with tarry stools. He has no abdominal pain. He takes non-steroidal anti-inflammatory drugs (NSAIDs) intermittently for pain control.
•Temperature 37°C, pulse 120 bpm, BP 100/60mmHg, SaO2 98-100% on RA.
•Hydration is satisfactory.
•Examination of the hands reveals no clubbing and normal-appearing palmar creases.
•Head and neck examination is unremarkable.
•Cardiovascular: HS dual, no murmur.
•His chest is clear on auscultation.
•Abdominal examination reveals a soft, non-tender abdomen.
•PR melaena.
•No signs of oedema.
Investigations
•CBC:
–WBC 9 x 109/L;
–haemoglobin 6.5g/dL;
–platelets 330 x 109/L.
•Urea 20mmol/L.
•Creatinine 80μmol/L.
•Liver function tests are normal.
What is your differential diagnosis?
•Peptic ulcer bleeding (most likely).
•Upper GI neoplasm.
•Oesophageal or gastric varices — less likely as the patient does not have a history of chronic liver disease.
•Mallory-Weiss syndrome — less likely as the patient did not have preceding retching/vomiting.
•Angiodysplasia.
•Dieulafoy’s lesion.
What further investigations would you order?
•Erect chest X-ray (CXR) (for free gas under the diaphragm to rule out perforation).
•Oesophagogastroduodenoscopy (OGD).
CXR shows no free gas under the diaphragm. ECG shows a normal sinus rhythm.
An OGD is performed showing the pathology below (Figure 35.1).
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Please describe what you see
This endoscopic image shows a distal D1/2 posterior wall ulcer with a visible vessel.
Adrenaline injection around the visible vessel followed by heater probe application is performed. The visible vessel is obliterated and the ulcer cavitated. A rapid urease test is negative.
What treatment should be given next?
An intravenous (IV) proton pump inhibitor (PPI) bolus, followed by a PPI infusion for 72 hours should be given to reduce the risk of rebleeding 1, 2.
Supportive transfusion is given. What is the target level of haemoglobin?
Hb ≥7g/dL in haemodynamically stable patients.
A restrictive transfusion strategy with transfusion given only when the haemoglobin level falls <7g/dL is associated with a better 6-week survival, less rebleeding and less complications 3.
