1. Case 1: Upper GI Bleeding
Group D
Mamba - Medenilla

2. Case 1: Upper GI Bleeding
O.L. , 65 y/o, female
Chief complaint
MELENA
Melena – passage of black, foul-smelling tarry stool

3. History of Present Illness
6 months PTA
Vague epigastric discomfort
Did not seek consultation
Did not take any medication
2 days
PTA
Present
Melena
No abdominal pain
10 kg weight loss (past 6 months)
2 episodes of melena (2 cupfuls per episode)
1 episode of coffee-ground vomiting
Cold clammy sweats
Dizziness
2 days PTA – 2 episodes of melena (2 cupfuls per episode)

4. Past Medical History Osteoarthritis (5 years ago)
Diclofenac Na intermittently
Last intake: 1 week PTA
(+) Hypertension, diabetes for 15 years
Medications
Losartan, metformin/sitagliptin (Janumet), clopidogrel, simvastatin

5. Physical Examination Vital signs: Weight: 68 kg Height: 160 cm
BP 120/80 (supine), 100/60 (sitting)
PR 105/min
RR 22/min
Temperature: 37.2°C
Weight: 68 kg
Height: 160 cm
160 cm = 5’3”
BMI: 26.6

6. Physical Examination Pale palpebral conjunctiva Abdomen
Hyperactive bowel sounds
Anicteric sclera
Soft, non-tender, no palpable masses, no organomegaly
No cervical lymphadenopathy
DRE
Maroon colored stools
Normal heart and lung sounds
Apex beat at 6th LICS

7. Chief Complaint: MELENA
Passage of black, tarry, and foul-smelling stools
Caused by a delivery of at least 50 mL of blood into the upper gastrointestinal tract
Degradation of blood to hematin or other hemochromes by bacteria
Blood has been present in the GI tract for at least 14 hours
Melena is one of the possible clinical presentations of gastrointestinal bleeding
Volumes of up to 100 mL may be clinically silent
Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, 8th ed.
Harrison’s Principles of Internal Medicine, 17th ed.

8. APPROACH TO THE PATIENT: Gastrointestinal Bleeding

9. APPROACH TO THE PATIENT: Gastrointestinal Bleeding
Immediate assessment
Stabilization of hemodynamic status
Determine the source of bleeding
Stop active bleeding
Treat underlying abnormality
Prevent recurrent bleeding

10. APPROACH TO THE PATIENT: Gastrointestinal Bleeding
Immediate assessment
Heart rate
Blood pressure
Patient’s Hemodynamic Status (Vital Signs)
Blood Loss (% of
Intravascular Volume)
Severity of Bleed
Shock (resting hypotension)
20-25
Massive
Postural (orthostatic hypotension and tachycardia)
10-20
Moderate
Normal
<10
Minor
Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, 8th ed.

11. APPROACH TO THE PATIENT: Gastrointestinal Bleeding
Resuscitation
Restore and maintain normal vital signs
History and physical examination
Preliminary assessment of the site and cause
Resuscitation:
Infusion of intravenous fluids (normal saline or lactated Ringer’s)
Supplemental oxygen
Blood transfusion (unstable vital signs, continued bleeding, symptoms of poor tissue oxygenation, or persistently low Hct values (20-25%)
Age
Elderly: diverticula, ischemic colitis, cancer
Younger patients: ulcer disease, esophagitis, or varices
Abdominal pain (peptic ulcer dse, mesenteric or colonic ischemia)
Retching (Mallory-Weiss tear)
Change in bowel habits, anorexia, or weight loss (malignancy)
PE:
Signs of portal HPN (spider angiomata, Dupuytren’s contractures, splenomegaly, ascites, caput medusae)
Malignancy (acanthosis nigricans - velvet warty benign growths and hyperpigmentation occurring in the skin of the axillae, neck, anogenital area, and groin; abdominal masses, lymphadenopathy)
Abdominal tenderness (peptic ulcer, pancreatitis, ischemia)
Cirrhosis and splenic vein thrombosis (splenomegaly)
Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, 8th ed.

12. APPROACH TO THE PATIENT: Gastrointestinal Bleeding
Differentiation of upper from lower GIB
Upper GIB
Lower GIB
Hematemesis
Hematochezia
Melena
Hyperactive bowel sounds
Elevated BUN
Hematemesis – vomitus of red blood or “coffee-grounds” material
Melena – black, tarry, foul-smelling stool
Hematochezia – passage of bright red or maroon blood from the rectum
Elevated BUN – due to volume depletion and blood proteins absorbed in the small intestine
Harrison’s Principles of Internal Medicine, 17th ed.

13. APPROACH TO THE PATIENT: Gastrointestinal Bleeding
Differentiation of upper from lower GIB
Patient
Melena, hematemesis, and hyperactive bowel sounds
Upper GIB
Lower GIB
Hematemesis
Hematochezia
Melena
Hyperactive bowel sounds
Elevated BUN
Hematemesis – vomitus of red blood or “coffee-grounds” material
Melena – black, tarry, foul-smelling stool
Hematochezia – passage of bright red or maroon blood from the rectum
Elevated BUN – due to volume depletion and blood proteins absorbed in the small intestine
Harrison’s Principles of Internal Medicine, 17th ed.

14. APPROACH TO THE PATIENT: Gastrointestinal Bleeding
Differentiation of upper from lower GIB
Patient
Melena, hematemesis, and hyperactive bowel sounds
Upper GIB
Lower GIB
Hematemesis
Hematochezia
Melena
Hyperactive bowel sounds
Elevated BUN
Hematemesis – vomitus of red blood or “coffee-grounds” material
Melena – black, tarry, foul-smelling stool
Hematochezia – passage of bright red or maroon blood from the rectum
Elevated BUN – due to volume depletion and blood proteins absorbed in the small intestine
Harrison’s Principles of Internal Medicine, 17th ed.