CHIEF COMPLAIN

• Mr SK, a 50 year old Indian man, with underlying IHD and DM

referred from GP presented to the ED with a complain epigastric
pain, melena, vomitting, giddiness, blurring of vision and postural
hypotension for 1/52
HISTORY OF PRESENTING ILLNESS

• Epigastric pain
• For the past 2/12
• Constant, constricting pain
• Radiation to the left chest
• a/w diaphoresis
• Relieved by rest
• No aggravating factor
• Been taking gastric medication
• Took GTN a day prior to admission
• Pain score 2-8/10
• Worsening pain for the past 1/52
• Melena
• Once daily for the past 1/52
• Tenesmus
• No fresh blood
• Not painful
• Vomiting
• Two times, day 4 of illness (3 prior to admission)
• Moderate amount
• Coffee ground stained
• Episode of giddiness after vomiting
• Reduced effort tolerance
• No chest pain
• No shortness of breath
• No palpitation
• No syncopal episodes
• No loss of weight
• No loss of appetite
PAST MEDICAL & SURGICAL

• IHD
• April 2017
• COROS + PCI done on April and July (2 vessel stenting)
• On Dual Antiplatelet Theraphy
• DM
• Was found to have DM during admission on April
MEDICATION LIST

• Tablet (T.) Cardiprin 100mg OD

• T. Ticagrelor 90mg BD
• T. Metformin 850mg BD
• T. Telmisartan 40mg OD
• T. Bisoprolol 1.25mg OD
• T. Atorvastatin 40g OD

• No know food or drug allergy

FAMILY HISTORY

85 year old
DM
SOCIAL HISTORY

• Married and blessed with 3 children

• Own business
• Living in Bandar Mahkota Cheras
• Non-smoker
• Occasional alcohol drinker. Stopped taking alcohol since April
SUMMARY

• Mr SK, a 50 year old Indian gentleman, with DM and IHD on DAPT,

came in to ED with a complain of epigastric pain, vomitting,melena,
giddiness, blurring of vision and postural hypotension for the past
1/52.
 Physical Examination
General Inspection:
Patient is alert, conscious and cooperative. He’s appeared sallow looking. However
he’s not in pain or respiratory distress. There’s branula attached at the dorsal part of
the right hand which connected to intravenous Nexium pump infusion. Patient’s also
on cardiac monitoring.

Vital Sign:
Blood Pressure: 180/122 mmHg
Pulse Rate: 84 bpm, good volume, normal rhythm regularly regular
Respiratory Rate: 14 bpm
SpO2: 100%

Peripheral Examination:
Warm periphery, sallow looking palm, CRT <2s, no peripheral cynosis, no stigmata of
chronic liver disease.
There’s presence of conjunctival pallor and pale mucosa. Apart from that, good
hydration status, good mouth hygiene, no central cynosis, no glossitits and angular
stomatitis.
Abdominal Examination

The abdomen is not distended, move with respiration, no scar noted,

no obvious mass and no dilated superficial vein.

On palpation, the abdomen is soft and non tender. There’s no mass

palpable, no hepatosplenomegaly. The liver span is around 9cm. The
kidneys are not ballotale. There’s positive shifting dullness. Bowel
sound is present and normal and there’s no renal bruit.

There’s presence of pedal oedema up to shin. Apart from that, there’s

no sacral oedema, no lymphadenopathy and also no bibasal
crepitations noted.

Per rectal examination was done at the ED. No melena or blood was
noted.

Other Systemic Examination

Normal findings
Differential Diagnosis
1.UGIB secondary to aspirin induced peptic ulcer
disease
2. Gastritis
3. Oesophageal varices secondary to portal
hypertension
4.Gastric cancer
5.Recurrent MI
Investigation
 Result FBC (11-13/12/2017)
Parameters Result (11/12) Result (12/12) Reference value

WBC 5.3 6.0 4.1-11.4 x 109/L

Red cell count 2.4 3.3 4.5-6.0 x 1012/ L

Hemoglobin 6.7 9.3 13.5-17.4 g/dL

Hematocrit 21.6 28.6 40.1-50.6 %

MCV 90.8 85.9 80.6-95.5 fl

MCH 28.2 27.9 26.9-32.3 pg

MCHC 31.0 32.5 31.9-35.3 g/dL

RDW 15.8 15.1 12.0-14.8 %

Platelet 194 197 142-350 x 109/L

Neutrophils 3.2 4.1 3.9-7.1 x 109/L

Eosinophil 0.2 0.2 0.0-0.8 x 109/L

Basophils 0.0 0.0 0.0-0.1 x 109/L

Lymphocytes 1.5 1.3 1.8-4.8 x 109/L

Monocytes 0.4 0.3 0.4-1.1 x 109/L

Nucleated RBC 0.00 0.00 0.0-0.0 x 109/L

 Result RP (11/12/2017)
Parameters Result Reference value
Sodium 142 136-145 mmol/L
Potassium 4.4 3.5-5.1 mmol/L
Urea 6.4 3.2-7.4 mmol/L
Creatinine 107.4 63.6-110.5 mmol/L

Result RP (12/12/2017)
Parameters Result Reference value
Sodium 141 136-145 mmol/L
Potassium 4.3 3.5-5.1 mmol/L
Urea 4.9 3.2-7.4 mmol/L
Creatinine 111.9 63.6-110.5 mmol/L
 Result LFT (11/12/2017)
Parameters Result Reference value
Albumin 35 35-50 g/l
Total protein 63 64-83 g/l
Bilirubin 10.5 3.4-20.5 umol/l
ALT 30 0-55 U/L
ALP 83 40-150 U/L
Amylase 100 25-125 U/L
Calcium 2.14 2.10-2.55 mmol/L
Corrected calcium 2.24 2.14-2.58 mmol/L
Phosphate 1.02 0.74-1.52 mmol/L
Magnesium 0.73 0.66-1.07 mmol/L
 Result Coagulation Profile
(11/12/2017)

Parameters Result Reference value

PT (Patient) 12.4 11.6-14.1 Seconds
PT (Control) 12.8 secs
INR 0.96 Ratio
APTT (Patient) 35.3 30.16-44.29
Seconds
APTT (Control) 38.7 secs
APTT Ratio 0.91 0.89-1.32 Ratio
ECG (11/12/2017)

• Normal ECG, sinus rhythm

Timeline of management
11/12
•Pt presented to ED with the vital sign and Hb
below
• Pulse rate: 88 /min Management given:
• Respiratory rate: 18/min 1. Acute resuscitation (ABC)
2.IV Nexium 80mg stat followed by infusion
• Blood pressure: 159/92 mmHg 3. Blood transfusion 2 pint (Indication : Angina or
• SpO2: 100% under room air cardiovascular disease with a Haemoglobin <10g/dl)
4. Withhold DAPT (aspirin 100mg + Ticagrelor 90mg)
• GCS: 15/15
• Temperature : 37 oC
• Hb: 6.7 g/dl
• RP, LFT, coagulation profile within normal range
Timeline of management
12/12
• Hb improve to 9.3 g/dl after 2 pint of blood transfusion
• Patient went to Oesophageal-gastro-duodenalscopy (OGDS)
• Result : Forrest IIc ulcer at pyloric region near D1, no endoscopic haemostasis
done.
• Post-endoscopic
• To restart T.Aspirin 100mg OD after endoscopy and restart T.clopidogrel
75mg on Friday after discussed with cardiologist
• IV Nexium 40mg bd and change into T.Nexium 40mg bd until complete DAPT
• Patient was transfuse another 2 pints of blood (Indication: Angina or
cardiovascular disease with a Haemoglobin <10g/dl)
OGDS (12/12/2017)

PYLORIC ANTRUM

Gastritis by evidence of inflammation

Forrest 2C ulcer at pyloric region near D1
Forrest classification of peptic ulcer
Timeline of management
13/12
• After another two pint of blood transfusion, Hb increase to 10.9 g/dl
• Patient is asymptomatic and haemodynamically stable
• Patient was discharged with the following plan
• T.CARDIPRIN 1/1 OD 6/52
• T.PLAVIX 75MG OD (RESTART ON FRIDAY) 6/52
• T.NEXIUM 40MG BD FOR 6/52
• S/L GTN 0.5MG PRN
• T.BISOPROLOL 1.25MG
• T.ATORVASTATIN 40MG ON
• T.Metformin 850mg BD
• T.GLICLAZIDE 60MG OD
• TCA surgical clinic 6/52
• Acute management in ED
• Pre-endoscopy management
• Endoscopy (diagnostic + therapeutic)
• Post endoscopy management
 Acute management
• Airway – Maintain the airway, if patient is drowsy or comatose,
consider intubation with cuffed endotracheal tube to protect the
airway from aspiration
• Breathing – Provide supplemental oxygen to maintain SpO2 >
94%
• Circulation – Insert two or more large bore peripheral IV line
(14/16G)
• If patient is haemodynamically unstable , infuse 1L of normal
saline rapidly and consider blood transfusion* if no significant
improvement after initial fluid challenge
• If patient is haemodynamically stable, start NS 500ml over 1-2
hour
• Blood Ix: GXM, FBC, RP, Coagulation profile, LFT
• IV Esomeprazole 80mg stat followed by infusion 8mg/h
Indication of blood transfusion (CPG Malaysia, 2003)
1. Systolic BP < 110 mmHg
2. Postural hypotension
3. Pulse > 110/min
4. Haemoglobin <8g/dl
5. Angina or cardiovascular disease with a Haemoglobin <10g/dl

Diagnosis and management of nonvariceal upper gastrointestinal

hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE)
Guideline, 2017
 Risk stratification

• Score 0-1: Patient can be

discharge from ED and
manage as outpatient
without in patient endoscopy.
• In this patient, the GBS score
is 7, therefore he shouldn’t
be discharge and require
inpatient endoscopy
 Pre-endoscopy management
• All anticoagulant or antiplatelet should be stop before endoscopy
• If the clinical situation allows, ESGE suggests an international
normalized ratio (INR) value< 2.5 before performing endoscopy
with or without endoscopic hemostasis (weak recommendation,
moderate quality evidence).
• Pre-endoscopy high dose IV proton pump inhibitors bolus
followed by continuous infusion (80mg then 8mg/h) decrease
the incidence of high risk stigmata of haemorrhage at time of
index endoscopy and the need for endoscopic hemostasis.
• However PPI infusion should not delay the performance of early
endoscpy
• Uses of tranexamic acid and somatostatin analogue is not
recommended in patient with NVUGIB
Timing of endoscopy
Endoscopic management
Post-endoscopy management
How common?

• Luis A. Garcia et al (2016)

• The incidence of GI bleeding with low-dose aspirin was 0.48-3.64 cases per
1000 person-year (RR 1.4)
• Relative risk for upper and lower GI bleeding was 2.3 (2.0–2.6) and 1.8 (1.1–
3.0), respectively.
• RR for ICH with low-dose aspirin was 1.4 (1.2–1.7) overall.

• Y.K Loke et al (2000)

• GI haemorrhage occurred in 2.47% of patients taking aspirin compared with
1.42% taking placebo (OR 1.68)
Risk factor
1. History of peptic ulcer disease or gastrointestinal bleeding,
2. older age,
3. concomitant use of NSAIDs
4. concomitant use of anticoagulants or other platelet aggregation
inhibitors,
5. presence of severe co-morbidities (ie Diabetes)
6. high aspirin dose.

Protective factor
1. Use of PPI

Source: Hsu PI et al(2015), Vera E. Valkhoff et al(2012)

Management of variceal bleed?
• Slightly different from non-variceal bleed
• Primary prophylaxis: non-selective beta blocker, and screening endoscopy at the
time of diagnosis of cirrhosis and every 2 years in patients not known to have
varices.
• A vasoactive (vasopressin, terlipressin, somatostatin etc) drug should be started
as early as possible from the time of admission or even upon the patient’s
transfer to the hospital.
• Endoscopy management: Endoscopic variceal ligation or sclerotherapy
• Consider Transjugular Intrahepatic Portosystemic Shunts (TIPS) , reduce portal
hypertension
• Secondary prophylaxis: Non-selective beta-blockers (such as pronanolol) should
be used for secondary prophylaxis.

Source: CPG Management on variceal bleeding , ministry of health,

Malaysia, 2007