Clinical Case:

1. 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.

2. 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.

3. 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.

4. Questions: • What is likely to have occurred with this gentleman? • What is the differential diagnosis? • What are your management priorities?

5. Differential Diagnosis: • Bleeding peptic ulcer: • Gastric / duodenal • Bleeding oesophageal varices • Mallory-Weiss syndrome (Oesophageal Tear) • Haemorrhagic alcoholic gastritis • Gastric neoplasm eroded bleeding vessel.

6. 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

7. 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?

8. 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.

9. 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.

10. 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.

11. 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.

12. 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

13. 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 years 2 rebleeds if < 60 years High transfusion requirement: Age > 50 years 4 units Age < 50 years 6 units