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 lt 8 or HM 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
• UEs, 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 gt 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 gt 60 years 2 rebleeds if lt 60 years
• High transfusion requirement
• Age gt 50 years 4 units
• Age lt 50 years 6 units