Anemia sec to UGIB

GENERAL DATA

 D. S.
 67years old / male
 5 M Proto st. San Roque, city of marikina
 Roman Catholic
 Filipino
CHIEF COMPLAINT

Pallor and Melena

HISTORY OF PRESENT ILLNESS

1 year
 Pt experienced diarrhea with passage of black tarry
stool, foul smelling and 3 episodes of passage per
day. Pt also noticed weight loss, easy fatigability and
anorexia. Pt. decided to to seek consult in QMMC
due to signs and symptoms and was admitted for 3
weeks due to decrease in hemoglobin levels. Different
examinations were done and discharged was settled.
Pts
HISTORY OF PRESENT ILLNESS

 Pts. Take home meds were Losartan, Candesartan and Glicazide. Pt was also requested
to have a follow up check up in OPD for re examinations and improvement.
 During the interim
 Pt did not note any bleeding and signs and symptoms of the previous year was
unremarkable
 1 month PTC
 Recurrence of passage of dark tarry stools were noted. Only the medications that were
prescribed on the previous year was continued. No consultation were done.
 FHPTC
 Pt notice pallor, easy fatigability, shortness of breath and insomnia. Hence consult was
made
PAST MEDICAL HISTORY

 + Hypertension for 30 years

 Amplodipine
 DM for 30 years
 Insulin 1 unit g mol
 - surgeries
 + hospitalization
 UGIB 2018
FAMILY HISTORY

 + hypertension mother and father side

 + diabetes mother
PERSONAL AND SOCIAL
HISTORY
 3 sibling
 Garbage collected by dump trucks every Friday
 House made out of cement 1 floor
 Water source for drinking is Nawasa
 Previous smoker
 18 pack years
 Previous alcoholic drinker
 1 bottle per day ( gin)
REVIEW OF SYSTEMS

 General: (+) weight loss, (-) weight gain, (+) decreased of appetite, (-) fever,
(+) easy fatigability, (+) weakness pallor
 HEENT: (-) dizziness, (+) lightheadedness, (-) eye redness, (-) eye discharge,
(-) blurring of vision, (-) ear pain, (-) ear discharge, (-) nasal discharge, (-) dry
mouth, (-) sore tongue, (-) hoarseness
 Neck: (-) lumps, (-) swollen gland, (-) pain/stiffness
 Gastrointestinal: (+) abdominal pain, (-) constipation, (+) diarrhea, (-)
jaundice
 Genitourinary: (-) bleeding, (-) urinary frequency, (-) hematuria, (-) dysuria,
(-) flank pain, (-) dribbling, (-) reduced caliber, (-) incontinence
 Musculoskeletal: (-) edema, (-) muscle pain, (-) joint stiffness
 Hematology: (-) easy bruising
 Endocrine: (-) heat/cold intolerance, (-) excessive nightsweating
PHYSICAL EXAMINATION

 General Survey: awake, alert , coherent, ambulatory, in respiratory

distress
 Vital signs: BP: 120/70, CR: 100 RR: 20 Temp: 36.9 °C
 SKIN: no lesions,, no hyperpigmentation and no hypopigmentation
 HEENT:, anicteric sclerae, pale conjunctiva, no nasal discharges and
no sinus tenderness, pale oral mucosa, symmetrical tonsils and not
enlarged
 NECK: no lesions, no masses, no lymphadenopathy
 PHYSICAL EXAMINATION

 Lung findings: symmetrical chest expansion, no chest lag, no chest

retractions, no masses/ lesions, equal tactile fremitus, resonant on
percussion, vesicular breath sounds, no whezzes
 Heart: adynamic precordium, Capillary refill time <5 secs, no
clubbing, no heaves or thrills palpated, distinct S1 and S2, PMI noted
at left 5th ICS MCL, no murmurs
ADMITTING DIAGNOSIS:

Anemia secondsary to UGIB

LABORATORIES
TEST NAME RESULT UNIT REFERENCE
RANGE
RBC count 2.34 X10^12 4.7-6.1
Hemoglobin 71.0 G/L 140-180
Hematocrit 0.21 VOL% 0.40- 0.54
WBC 12 X 10 5.0- 10
Eosinophil 0.07 0- 0.06
LABORATORIES
TEST NAME RESULT UNIT REFERENCE
RANGE
Prothrombin time
Protime 10.7 secs 10.5 – 12. 9
PT percent activity 122.0 %
PT INR 0.9
APTT
APTT 20 secs 22.7- 32.1
APTT normal 25.3 secs 20.9- 28.3
control
Definitions
 Upper GI bleed – arising from the
esophagus, stomach, or proximal duodenum
 Mid-intestinal bleed – arising from distal
duodenum to ileocecal valve
 Lower intestinal bleed – arising from
colon/rectum
Stool color and origin/pace of bleeding

 Guaiac positive stool

 Occult blood in stool
 Does not provide any localizing information
 Indicates slow pace, usually low volume bleeding
 Melena
 Very dark, tarry, pungent stool
 Usually suggestive of UGI origin (but can be small intestinal, proximal colon origin if slow
pace)
 Hematochezia
 Spectrum: bright red blood, dark red, maroon
 Usually suggestive of colonic origin (but can be UGI origin if brisk pace/large volume)
Differential Diagnosis – Upper GIB

 Peptic ulcer disease Most

common
 Gastroesophageal varices
 Erosive esophagitis/gastritis/duodenitis
 Mallory Weiss tear
 Vascular ectasia
 Neoplasm
 Dieulafoy’s lesion Rare, but cannot
 Aortoenteric fistula afford to miss

 Hemobilia, hemosuccus pancreaticus

Differential Diagnosis – Lower GIB

Most common
 Diverticulosis diagnosis
 Angioectasias
 Hemorrhoids
 Colitis (IBD, Infectious, Ischemic)
 Neoplasm
 Post-polypectomy bleed (up to 2 weeks after procedure)
 Dieulafoy’s lesion
History and Physical

History Physical Examination

• Localizing symptoms  Vital signs, orthostatics
• History of prior GIB  Abdominal tenderness
• NSAID/aspirin use  Skin, oral examination
• Liver disease/cirrhosis  Stigmata of liver disease

• Vascular disease
 Rectal examination
 Objective description of stool/blood
• Aortic valvular disease,
chronic renal failure
 Assess for mass, hemorrhoids
 No need for guaiac test
• AAA repair
• Radiation exposure
• Family history of GIB
Narrowing the DDx: Upper or Lower Source?

• Predictors of UGI source:

– Age <50
– Melenic stool
– BUN/Creatinine ratio
• If ratio ≥ 30, think upper GIB
Utility of NG Tube

 Mostuseful situation: patients with severe

hematochezia, and unsure if UGIB vs. LGIB
 Positive aspirate (blood/coffee grounds) indicates UGIB
 Can provide prognostic info:
 Red blood per NGT – predictive of high risk endoscopic
lesion
 Coffee grounds – less severe/inactive bleeding
 Negative
aspirate – not as helpful; 15-20% of patients
with UGIB have negative NG aspirate
Initial Assessment
 Assess degree of hypovolemic shock

Class I Class II Class III Class IV

Blood loss 750 750-1500 1500-2000 >2000
(mL)
Blood volume < 15% 15-30% 30-40% >40%
loss (%)
Heart rate <100 >100 >120 >140
SBP No change Orthostatic Reduced Very low,
change supine
Urine output >30 20-30 10-20 <10
(mL/hr)
Mental status Alert Anxious Aggressive/ Confused/
drowsy unconscious
Causes of Mortality in Patients with
Peptic Ulcer Bleeding
 Patients rarely bleed to
death
 Prospective cohort study
>10,000 cases of peptic
ulcer bleed
 Mortality rate 6.2%
 80% of deaths not
related to bleeding

Am J Gastroenterol 2010;105:84
 Causes of Mortality in Patients with
Peptic Ulcer Bleeding
 Most common causes of non-bleeding mortality:
 Terminal malignancy (34%)
 Multiorgan failure (24%)
 Pulmonary disease (24%)
 Cardiac disease (14%)

Am J Gastroenterol 2010;105:84
Rockall Scoring System
 Validated predictor of mortality in patients with UGIB
 2 components: clinical + endoscopic

Variable 0 1 2 3

Age <60 60-79 ≥ 80

Shock No Tachy- Hypotension-

SBP ≥ 100 SBP ≥ 100 SBP <100
P<100 P>100
Comorbidity No major Cardiac Renal failure,
failure, CAD, liver failure,
other major malignancy

Gut 1996;38:316
AIMS65

 Simple risk score that predicts in-hospital mortality, LOS, cost in patients with
acute UGIB

Albumin <3.0
INR > 1.5
Mental status altered
Systolic BP <90
65+ years old
Gastrointest Endosc 2011;74:1215
Approach to Upper
GI Bleeding
Initial Evaluation

 Major causes
 Peptic ulcer, esophagogastric varices, arteriovenous malformation, tumor, esophageal
(Mallory-Weiss) tear
 Characteristics of bleeding
 Hematemesis – coffee ground vs bright red blood
 Melena
 Hematochezia
 History
 Liver disease, alcoholism, coagulopathy
 NSAID, antiplatelet or anticoagulant use
 Abdominal Surgeries
 Examination
 Vitals
 Tachycardia, hypotension
 Abdominal examination
 Significant tenderness, organomegaly, ascites
 Rectal examination
 Skin examination
 NG lavage - if source of bleeding unclear
 Diagnostic Evaluation
 Hgb/Hct, plt count, coag studies
 LFTs, albumin, BUN and creatinine
 Type and screen /type and cross
Emergent Management

 Closely monitor airway, clinical status, vital signs, cardiac rhythm

  two large bore IV lines (16 gauge or larger)
 bolus infusions of isotonic crystalloid
 Transfusion
 pRBCs – Hgb <7, hemodynamic instability
 FFP, platelets – coagulopathy, plt <50 or plt dysfunction
 Triage – ICU vs Wards
 Hemodynamic instability or active bleeding > ICU
 Immediate GI consult
Medications

 Acid Suppression
 PPI
 Protonix 80mg IV bolus, then 8mg/hr infusion
 Esomeprazole at the same dose
 Somatostatin analogues
 Suspected variceal bleeding/cirrhosis
 Octreotide 50mcg IV bolus, then 50mcg/hr infusion
 Antibiotics
 Suspected variceal bleeding/cirrhosis
 Most common regimen is Ceftriaxone (1 g/day) for seven days
 Can switch to Norfloxacin PO upon discharge