Dulay, Eldorie

DIAGNOSIS: UGIB DUE TO PEPTIC ULCER DISEASE SECONDARY TO

HELICOBACTER PYLORI INFECTION
Signs & symptoms:
 Light headedness – caused by severe anemia.
 3 episodes of melena – sign of upper gastrointestinal bleeding, related
complication in PUD.
 Loss of appetite & nausea – indicative of an ulcer complication.
Risk Factors:
 Advanced age: 65 years old
 Intake of Diclofenac 50 mg tablet 2x a day continuously: NSAIDs are naturally
gastric irritant.
 History of CAD, s/p CABG, maintained of Clopidogrel 75mg tablet OD
 Hypertensive
 Previous alcoholic drinker, consuming 4 bottles of beer a day for 30 years.
 Family history of Gastric malignancy.
Physical Examinations:
 Patient is hypertensive with a regular BP of 140/90 but dropped to 120/80
(supine) 90/60 (sitting) and patient is tachycardic (HR: 110).
 HEENT: Palpebral conjunctivae: sign of severe blood loss.
 CVS: Tachycardic
 Extremities: pale palm
 DRE: blackish stool

CBC:
 Hgb: 7.9 g/dl & Hct 0.21 (severe anemia)
Endoscopy:
 Multiple erosion in the body and antrum ulcer, Forrest IIC with positive H. pylori
infection on rapid urease test.
Diagnostic Approach:
1. CBC: To check the level hemoglobin and hematocrit in assessing the severity of
anemia.
2. Endoscopy: To confirm if there are ulcers present and to determine if an ulcer is
a source of blood loss. Can be used to get a biopsy sample to rule out
malignancy.
3. Rapid urease test : To detect presence of H. pylori infection.