35

Case 35


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.


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.


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).


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).






images


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.

Only gold members can continue reading. Log In or Register to continue

You may also need

Oct 23, 2019 | Posted by in GASTROENTEROLOGY | Comments Off on 35
Premium Wordpress Themes by UFO Themes