Week 1 BGD: Differential Diagnoses and Approach to Patients Presenting with Upper GI Bleeding (UGIB) Presented to the Department of Medicine University of Santo Tomas Faculty of Medicine and Surgery Medicine 3 Module I (Hematology/ Oncology and Gastroenterology) Presented by Group 4 (Palacpac, K.- Phoa, T. et al)

Salient Features O. L., 65, F CC: Melena HPI: 6 mos PTA, started experiencing vague epigastric discomfort; did not seek consultations nor medications; there was also accompaniment of 10kg weight loss 2 days PTA, she had 2 episodes of melena (2 cupfuls/ episode) and 1 episode of hematemesis; accompanied by cold clammy sweats and dizziness Presently denies any abdominal pain Lacks data re: OLD CARTS OF PAIN, some epigastric pain maybe cardiovascular in origin The 10 kg wt loss is significant and maybe due to CA or malnutrition/ malabsorption d/t PUD Melena indicates the length of time blood is present in the GIT and is most likely directly proportional with a more proximal bleeding source; hematemesis indicates upper GI bleed; cool and clammy skin and sweats indicate vasoconstriction as a compensation most likely to hypovolemia secondary to UGIB

Salient Features Past Medical History: Diagnosed with osteoarthritis 5 years ago and takes Diclofenac Na intermittently (last intake 1 week PTA) Hypertensive and Diabetic for 15 years and takes losartan, metformin/ sitagliptin (Janumet), Clopidogrel and Simvastatin Diclofenac is a non- selective COX inhibitor and may cause GI ulcerations Metformin has gastrointestinal toxicity effects (anorexia, n/v, abdominal discomfort and diarrhea) in 20% of patients and vit. B12 deficiency

Salient Features Physical Examination VS: BP= 120/80 (supine) and 100/60 (sitting); PR= 105/min; RR= 22/min; Temp= 37.2 C 68 kg and 160cm Pale palpebral conjunctivae and anicteric sclera (-) cervical lymphadenopathies Lungs and heart sounds are normal Apex beat at 6 LICS Hyperactive bowel sounds, soft, non- tender, without palpable masses or organomegally DRE showed maroon colored stools Tachycardia maybe a compensatory mechanism for decreased intravascular volume d/t bleeding Pale palpebral conjunctiva maybe indicative of anemia or blood loss

Differential Diagnoses Peptic Ulcer Disease NSAID- Induced Gastropathy hemorrhagic or erosive gastropathy with alcohol Neoplastic Disease Mallory- Weiss Tears Variceal Bleeds Erosive Esophagitis Vascular Ectasias

Week 1 BGD: Data Collation and Diagnosis Presented to the Department of Medicine University of Santo Tomas Faculty of Medicine and Surgery Medicine 3 Module I (Hematology/ Oncology and Gastroenterology) Presented by Group 4 (Palacpac, K.- Phoa, T. et al)

Criteria for Identifying UGIB Causation Limited to Gastric CA, NSAID Induced Gastropathy and PUD Initial endoscopy with/ without radiologic imaging and biopsy epidemiology and demographics of 65 year olds in the development of Gastric CA; include studies relating weight loss and Gastric CA Incidence and relationship of NSAID use in the development of UGIB History and Physical Examination pointing out the risk factors for the development of PUD except for NSAIDs UGIB Diagnosis: UGIB due to PUD secondary to NSAID gastropathy

Findings if endoscopy and imaging studies are present Based on depth of invasion (greatest impact on outcome), macroscopic growth pattern and histologic subtype Early carcinoma is a lesion confined to the mucosa and submucosa regardless of the presence or absence of perigastric lymphnode metastasis Gross examination showing ill defined excavated central ulcer with irregular borders Histopathology includes gland formation by malignant cells that maybe invading the muscular wall or the diffuse type demonstrating signet- ring cells

Decision Points The group is only given physical examination and history data. No ancilliary procedures for support and documentation PUD and NSAID gastropathy outweighs Gastric CA in terms of timing and the relationship of NSAIDs and PUD (NSAID intake may lead to PUD) If epidemiology thru EBM shows that age and demographics are greater risk factors in the development of gastric CA as compared to NSAIDs as cause of PUD, the group can only rule out NSAIDs and/ or PUD but cannot rule in Gastric CA