Clinical

Case
REPO
GI Rotation
RT
September Batch
OCT17-OCT30,2022
MENTOR:
Group List
Name ID number Block

Borthakur, Adisha 18-0011-486 3

Borthakur, Bidisha 18-0019-243 3

Chauhan, Utkarsh 18-0191-698 3

De Sa, Roanna Francisca 18-0010-391 3

Ega, Srinivas 17-0636-479 4

Gautam, Priyesh Kumar 18-0060-796 4

Haritwal, Ashok 18-0039-187 4

Inbaraj, Bibisha Rajini 17-0617-845 4

Magendran, Tharun 17-0828-282 6B

Maan, Apoorv 18-0134-179 6B

About the
Patient
 Identifying Data
● 45 year old male
● Advertising executive
Chief complaint

Passage of black stools x 3

days and an associated
lightheadedness.
 History of Present Illness
● Patient developed easy fatigability
and generalized body weakness.
● His stools are not only black, but are
sticky and malodorous.
● Recent worsening of a chronic
epigastric burning which had been a
problem off/on for years.
  
 History of Present Illness
● He had doubled his usual dose of tums
without significant relief of the
burning.
● He takes NSAIDS as needed for back
pain and recently started on one
aspirin per day for cardiac
prophylaxis.
● He smokes two packs of cigarettes per
day and an occasional cigar.  
Past Medical History
● Hypertension
● No history of coronary artery
disease
● No abdominal surgeries
 Family Medical History

Unremarkable
Personal and Social History

2-3 martinis at lunch and

another cocktail before dinner
Review of Systems

• No weight loss
Good appetite
No easy bruisability  
 ● CBC:
Labs ○ Hemoglobin 9gm/dL,
○ Hematocrit 27%,
○ MCV 90,
○ WBC 13
○ PT/PTT – normal
● BUN 45mg/dL
● Creatinine 1.0 mg/dL
● Chest x-ray – normal
● X-ray of abdomen (kidney, ureter,
bladder - KUB) is unremarkable.
Vitals: ●
BP : 120/80 supine
● BP : 90/60 standing 
. ● HR : 110 
● RR : 20 
● Temp : 36.9%
● 02 sat : 95% room air
General Survey:
● Alert, oriented, overweight male
● Anxious and somewhat restless 
.● Anicteric sclera, pale palpebral
conjunctiva
● No active dermatoses, cool
extremities
● Symmetrical chest expansion, clear
breath sounds
● Distinct heart sounds, regular rhythm,
no audible murmurs
● Peripheral pulses are present but are
rapid and weak 
● Abdomen:
○ Flat abdomen, soft, with direct
tenderness in the epigastric area and
the left upper quadrant
○ Hyperactive bowel sounds
○ No palpable
○ No guarding or rebound tenderness
○ Liver not enlarged
○ Spleen not palpable, no masses
appreciated
● Rectal:
○ Good sphincteric tone,
○ No palpable masses
○ Black tarry stool 
● No motor or sensory deficits 
 Salient Features
● Passage of black stools x 3 days and an
associated lightheadedness.
● Easy fatigability and generalized body
weakness.
● Sticky and malodorous stool.
● Worsening of a chronic epigastric burning
which had been a problem off/on for years.
● Smokes two packs of cigarettes per day and
an occasional cigar
 Salient Features
● Takes NSAIDS as needed for back pain
● Recently started on one aspirin per day for
cardiac prophylaxis
● 2-3 martinis at lunch and another cocktail
before dinner
 Initial
Impression

Melena secondary to UGIB

Physical Examination Findings
● Change of BP from 120/80 mmHg to
90/60 mmHg standing (Orthostatic
Hypotension) : blood loss in stool
● HR of 110 due to hypovolemia (blood
in stool)
● Anxious and somewhat restless due to
dehydration and anemia
● Cool extremities due to vasoconstriction due to blood loss
● Pale palpebral conjunctiva due to anemia
● Weak and rapid peripheral pulses as a result of blood loss
(hypovolemia)
● Tenderness in the epigastric and left upper quadrant shows upper
GI pathology
● Hyperactive bowel sounds and black tarry stool suggests UGIB

Other PE findings unremarkable

Lab findings
● Hemoglobin of 9gm/dl (12-15 g/dL) : indicates
anemia
● Hematocrit of 27% (36-44%) : decreased red blood
cells due to UGIB
● WBC 13 (4-11x109/L) : suggests infection
● BUN 45 mg/dl (6-24 mg/dl): due to volume
depletion and blood proteins absorbed in the small
intestine
MCV 90, PT/PTT, Creatinine, Chest and Abdomen
 Ruptured Esophageal Varices
Rule in Rule out

● Black tarry ● Liver, spleen

stools and abdominal
● History of examination
alcohol intake normal
● Tachycardia ● PT normal
 Mallory-Weiss Tear
Rule in Rule out

● Black tarry ● Chronic

stools worsening of
● History of epigastric
alcohol intake pain
● Epigastric pain ● (-) Emesis
● (+)
Hypovolemic
state
● Needs
 Gastric Erosions
Rule in Rule out

● Black tarry stools ● (+) Good

● History of appetite
● (-) Weight loss
smoking and
● (-) Bloating
alcohol intake
● History of taking ● Need endoscopy
NSAIDS to r/o completely
● Epigastric pain
 Gastric adenocarcinoma
Rule in Rule out

● Black tarry stools ● (+) Good

● History of appetite
● (-) Weight loss
smoking
● Epigastric pain ● Normal
● Easy fatigability abdominal
● Generalized body examination
● Needs
weakness
endoscopy and
biopsy to
 Peptic ulcer disease
Rule in Rule out

● Black tarry Cannot be

stools ruled out
● Epigastric pain
● Anemia
● Chronic on and
off pain
● History of
aspirin and
 Diagnosis

UGIB secondary to Peptic Ulcer

Disease secondary to NSAIDS use
Types of GI bleeding
Based on presentation
Overt
Overt GIB is manifested by hematemesis,
vomitus of red blood or “coffee-grounds”
material
melena, black, tarry stool
and/or hematochezia, passage of red
or maroon blood from the rectum.
Occult
Symptoms of blood loss or anemia
such as lightheadedness, syncope,
angina, or dyspnea; or with iron-
deficiency anemia or a positive fecal
occult blood test on routine testing
Based on site of bleeding
UGIB (esophagus, LGIB Obscure GIB (if the
stomach, (colonic) source is unclear)

duodenum)
 Causes of UPPER GI bleeding

Peptic Esopha
Ulcers geal
varices
Mallory-
Weiss Erosive
tears disease
PEPTIC ULCERS:
1) Peptic ulcers are the most common cause of
UGIB,accounting for ~50% UGIB hospitalizations.

MALLORY-WEISS TEARS:
2) Accounts for ~2-10% of UGIB hospitalizations.
3) The classic history is vomiting,retching or coughing preceding
hematemesis, especially in an alcoholic patient
ESOPHAGEAL VARICES:
The proportion of UGIB hospitalizations due to varices ranges
widely from ~2-40%.
Patients with variceal hemorrhage have poorer outcomes than
patients with other sources of UGIB.

EROSIVE DISEASE :
Erosions are endoscopically visualized breaks which are confined
to the mucosa and do not cause major bleeding due to the
absence of arteries and veins in the mucosa.
 CAUSES OF
LOWER GI
BLEEDING
NSAID-induced erosions Vascular
and ulcers ectasias
Neoplasm Crohn’s
disease

Meckel’s Polyposis
diverticul syndromes
um
 Colonic sources of
GI BLEEDING
Hemorrho Anal
ids fissures
Radiatio
Vascular n
ectasias proctopa
thy Colit
is
Diverticul
osis Postpolypect
omy Neoplasm
Pathophysiology NSAID use

COX 2 COX 1 inhibition Topical

inhibition irritation

↓ Prostaglandins

↑ H+ production
↓ gastric mucous production and HCO3-
Neutrophil activation,
↑ Leukocyte adhesion,
Erosion of mucosa Epithelial damage
Inhibits cell healing,
↓ Epithelial cell renewal
Infection Erosion into blood vessel
↓ hematocrit
↑ WBC
BLEEDING ANEMIA
↓ hemoglobin
Blood passes
Breakdown of blood proteins through GI tract,
(hemoglobin, immunoglobulins) becomes oxidised
by HCl & digestion ● Pale palpebral conjunctiva
● Lightheadedness
MELENA ● Easy fatigability
↑ BUN ● Generalised body weakness
Black, sticky, malodorous stool
Management based on endoscopic findings
 Diagnostic Modalities
UGIB

Upper Endoscopy

Blood tests
Small intestine

Angiography

Push enteroscopy
CT enterography
Video capsule
endoscopy.
LGIB

Colonoscopy
Flexible
sigmoidoscopy
CT
Angiograph
Imaging
y
tests
Fecal occult
blood
Treatment
Management of active GI bleeding:
● Assess hemodynamic
stability
● Resuscitation
○ Intravenous fluids
○ Intravenous PPI
● +/- blood transfusion
Management of active GI bleeding:

● Upper Endoscopy
● Medical management
● If still bleeding surgical management
● Prevention of recurrent bleeding:
○ H.pylori eradication
○ Stop NSAID ans aspirin use
○ Indefinite PPI therapy
 References
Harrison’s Principles of Internal

Medicine 20th edition

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