Case 35


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.

Physical examination

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.



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.


Dieulafoy’s lesion.

What further investigations would you order?

Erect chest X-ray (CXR) (for free gas under the diaphragm to rule out perforation).

Electrocardiogram (ECG).

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).


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.

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Oct 23, 2019 | Posted by in GASTROENTEROLOGY | Comments Off on 35

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