CASE PRESENTATION ON UGI

BLEED 2⁰ TO DUODENAL ULCER

PRESENTED BY: SALMA WAJID
ROLL NO: 170722882013
PHARM-D SECOND YEAR

PRESENTED TO: DR. MARYAM

ASSISTANT PROFESSOR
DEPARTMENT OF PHARMACY PRACTICE
INTRODUCTION
Gastrointestinal bleeding is when there is blood loss
from any of the several organs included in your
digestive system. It can occur from any part of the
GI tract that runs from your mouth to your anus.
Upper GI bleeds stem from issues with your:
▪ Oesophagus.
▪ Stomach.
▪ Duodenum (first part of your small intestine).
ETIOLOGY
•Peptic ulcer. This is the most common cause of upper GI bleeding. Peptic ulcers are open sores that
develop on the inside lining of your stomach and the upper part of your small intestine. Stomach acid,
either from bacteria or use of anti-inflammatory medicines, such as ibuprofen or aspirin, damages the
lining, causing sores to form.

•Mallory-Weiss tears: Tears in the lining of the esophagus can cause a lot of bleeding. These are most
common in people who drink alcohol to excess, leading to vomiting.

•Esophageal varices due to portal hypertension: Enlarged veins in the esophagus, as a

complication of portal hypertension. This condition occurs most often in people with serious liver
disease, most commonly due to excessive alcohol use.
•Esophagitis. This inflammation of the esophagus is most often caused by
gastroesophageal reflux disease (GERD).

•Abnormal blood vessels. At times abnormal blood vessels, small bleeding

arteries and veins may lead to bleeding.

•Hiatal hernia. Large hiatal hernias may be associated with erosions in the
stomach, leading to bleeding.

•Growths. Though rare, upper GI bleeding can be caused by cancerous or

noncancerous growths in the upper digestive tract.
SIGNS AND SYMPTOMS
▪ Abdominal cramping.
▪ Black/ tarry stools or regular-colored stools
with blood in it.
▪ Pale appearance.
▪ Shortness of breath (dyspnea).
▪ Tiredness
▪ Vomit with blood in it or a substance that looks like
coffee grounds.
▪ Weakness and fatigue.
PATHOPHYSIOLOGY

H. pylori INFECTION NSAIDS

DIRECT MUCOSAL DAMAGE SYSTEMIC INHIBITION

DIRECT OR TOPICAL
IRRITATION OF THE GASTRIC OF COX-1 ENZYME
EPITHELIUM
ALTERATION IN
IMMUNE/INFLAMMATORY DECREASED
RESPONSE GASTRIC MUCOSAL DAMAGE SYNTHESIS OF
PROSTAGLANDINS

GASTRITIS AND PEPTIC ULCER PEPTIC ULCER

MUCOSAL DAMAGE

PEPTIC ULCER
DIAGNOSIS
▪ Blood tests: check for signs of GI bleeds, such as anemia, using a sample of your blood.
▪ Fecal occult blood test (FOBT ) is a lab test that checks for signs of blood in a stool sample.
▪ CT scan is a sophisticated imaging study that uses technology to produce 3D, enhanced views of
your intestines.
▪ GI X-rays take images of your upper or lower digestive tract to check for signs of a bleed or other
conditions. The tests use a barium contrast solution that makes it easier to see the digestive tract on
the X-ray.
▪ Upper endoscopy is a procedure to examine symptoms of an upper GI bleed. It uses a long tube with
a camera and light at the tip (endoscope).
▪ Balloon enteroscopy is like an endoscopy. It uses long tubes and a camera. Tiny balloons at the
endoscope tip inflate to help providers examine hard-to-reach small bowel.
▪ Colonoscopy or sigmoidoscopy is a procedure to examine signs of a lower GI bleed. The test uses
endoscopes that are passed through the anus.
TREATMENT
Medicines to treat ulcers may include:
▪ Antibiotics. These bacteria-fighting medicines are used to kill the H. pylori bacteria. Often
a mix of antibiotics and other medicines is used to cure the ulcer and get rid of the
infection.
▪ H2-blockers (histamine receptor blockers). These reduce the amount of acid your
stomach makes by blocking the hormone histamine. Histamine helps to make acid.
▪ Proton pump inhibitors or PPIs. These lower stomach acid levels and protect the lining
of your stomach and duodenum.
▪ Mucosal protective agents. These medicines protect the stomach's mucus lining from
acid damage so that it can heal.
▪ Antacids. These quickly weaken or neutralize stomach acid to ease your symptoms.
 PATIENT DEMOGRAPHIC PROFILE
AGE GENDER ALLERGIES DEPARTMENT
28 Y MALE NKA GASTROENTEROL
OGY

CHIEF COMPLAINTS:
Abdominal pain since 2 to 3 months VITALS:
Hematemesis CVS: S1S2 +
Melena CNS: NAD
RS: BAE+
HISTORY OF PRESENTING ILLNESS: P/A: SOFT
Chronic pancreatitis BP: 140/100 MM HG
S/P ESWL

PAST HISTORY:
No h/o DM / HTN
PROVISIONAL DIAGNOSIS: UGI BLEED
MEDICATION CHART
DAY NOTES:
Medication Dose Frequency ROA

DAY 1 Inj.Lintaz 1.25g BD IV

Inj. Lysomep 40mg IV BD
VITALS: Inj. Zofer 40 mg IV TID
TEMP: 98 F
Inj. Buscopan 20mg IV BD
BP: 140/100 mm /HG
PR:84 bpm Inj. Perinorm IV Stat
RR: 18/min Inj. Tramadol 50mg IV SOS
Syp. Sucral-O 10ml P/O TID
C/O: Abdominal pain
since 2 to 3 months, Tab. Pantocid 750/40/500 mg P/O BD
hematemesis, melena HP kit

O/E: Pt C/C/C
 DAY 02 DAY 03 DAY 04 DAY 05

TEMP: 101 °F TEMP: 98.3°F TEMP: 98.4°F TEMP: 98.4°F

BP: 130/80 mmHg BP: 130/70 mmHg BP: 110/80 mmHg BP: 110/80 mmHg
VITALS
PULSE: 83 bpm PULSE: 81 bpm PULSE: 83 bpm PULSE: 83 bpm
RR: 18/min RR: 20/min RR: 19/min RR: 19/min

No fresh No fresh No fresh

C/O No fresh complaints
complaints complaints complaints

O/E Pt is C/C/C Pt is C/C/C Pt is C/C/C Pt is C/C/C

Rx Rx Rx Rx
CST- INJ PERINORM CST CST+ CST
TAB CARDIVAS+ INJ
-INJ LINTAZ + TAB PAN PARACETAMOL- Inj
LIPASE BUSCOPAN
MEDICATION CHART
LAB INVESTIGATIONS
CBP:
PARAMETER RESULT NORMAL VALUES
Haemoglobin 8.0 gm/dl 13-17
RBC 2.8 million/cumm 4.5-5.5
HCT 24.9 % 38-50
WBC 3820 cumm 4000-11000
Lymphocytes 19% 20-40
Neutrophils 69% 40-80
Eosinophils 04% 01-06
Monocytes 08% 02-10
Platelets 1.2 lakhs/cumm 1.5-4.5
SERUM AMYLASE

PARAMETER RESULT NORMAL VALUES

Serum amylase 89 U/L 22-80

SERUM LIPASE

PARAMETER RESULT NORMAL VALUES

Serum lipase 7 U/L 7-39

SERUM ELECTROLYTES UGIE REPORT :

PARAMETER RESULT NOMRAL VALUES
Superficial duodenal
Na+ 141 mmol/L 136-145 ulcer-Forrest 3
K+ 3.9 mmol/L 3.5-5.0
Cl- 104 mmol/L 95-105
TREATMENT CHART:
MEDICATION CHART
Medication Generic name Dose Frequency ROA Category/indication
Inj. Lintaz Piperacillin/ Tazobactum 1.25g BD IV Anti bacterial
Inj. Lysomep Domperidone/pantoprazole 40mg IV BD GIT regulators, Antacids
Inj. Zofer Ondansetron 40 mg IV TID Anti emetic
Inj. Buscopan Hyoscine Butylbromide 20mg IV BD To reduce abdominal pain
Inj. Perinorm Metoclopramide IV Stat To reduce nausea, vomiting
Inj. Tramadol Tramadol 50mg IV SOS To alleviate abdominal pain
Syp. Sucral-O Sucralfate+ oxetacaine 10ml P/O TID To treat duodenal ulcer
Tab. Pantocid Amoxycillin+ Pantoprazole+ 750/40/500 P/O BD Antibacterial/ Antacid
HP kit clarithromycin mg
Tab. Pan lipase Pancreatin 10000u P/O TID For pancreatic enzyme
insufficiency
Tab. Cardivas Carvedilol 3.125mg P/O OD To reduce heart rate
Inj. PCM Paracetamol 1g IV TID To treat fever
SOAP ANALYSIS:
▪ SUBJECTIVE:
A 28 year old male patient was admitted with complaints of pain in abdomen since 2- 3
month.

Hematemesis

Melena

History of presenting illness:

Chronic pancreatitis

h/o : S/P ESWL

Past history:

No h/o HTN/DM
OBJECTIVE:
▪ Lab investigations revealed decreased levels of
haemoglobin, RBC, HCT, WBC, Lymphocytes and
Platelets.
▪ Serum amylase levels were found to be abnormally high.
▪ UGI endoscopy revealed large superficial duodenal ulcer.
ASSESSMENT
▪ According to the subjective and objective data obtained, the patient was
diagnosed with UGI bleeding secondary to duodenal ulcer.

PROBLEM: Bacterial infection

MEDICAMENT: inj. Lintaz, Tab. Pantocid HP kit

PROBLEM: Abdominal pain

MEDICAMENT: Inj. Buscopan, Inj. Tramadol
PROBLEM: Nausea, vomiting
MEDICAMENT: Inj. Zofer, Inj. Perinorm

PROBLEM: Duodenal ulcer

MEDICAMENT: Syp. Sucral-O, Tab. Pantocid HP kit
PLAN
▪ Lintaz/1.25g/IV/BD

▪ Lysomep/40mg/IV/BD

▪ Zofer/40mg/IV/TID

▪ Buscopan/20mg/IV/BD

▪ Perinorm/IV/ stat

▪ Tramadol/ 50mg/IV/SOS

▪ Sucral-O/ 10ml/P/O/ TID

▪ Pantocid HP kit/ P/O/ BD

▪ Pan lipase/10000 U/ P/O / TID

▪ Cardivas/ 3.125mg/ P/O /OD

▪ Paracetamol/ 1g/ IV/ TID

▪ Normal saline, RL @100ml/hr

PHARMACIST INTERVENTIONS:
▪ DRUG-DRUG INTERACTIONS:
▪ CLARITHROMYCIN+ONDANSETRON

INTERACTION: both clarithromycin and ondansetron are known to increase QT interval;

coadministration may result in additive prolonged QT interval and irregular heart rhythms.
MANAGEMENT: Avoid/ Use alternate drug. Monitor closely.
If concurrent use is required, administer beta blockers to help shorten QT interval.
▪ CLARITHROMYCIN+ TRAMADOL

INTERACTION: both clarithromycin and ondansetron are known to increase QT interval;

coadministration may result in additive prolonged QT interval and irregular heart rhythms.
MANAGEMENT: Avoid/ Use alternate drug. Monitor closely.
If concurrent use is required, administer beta blockers to help shorten QT interval.
▪ CLARITHROMYCIN+ PIPERACILLIN

INTERACTION: Clarithromycin decreases effect of piperacillin by pharmacodynamic antagonism.

MANAGEMENT: AVOID/ USE alternate drug. Monitor closely.
PATIENT COUNSELLING:
▪ REGARDING DISEASE:
▪ Upper gastrointestinal bleeding refers to bleeding that occurs in upper part of the
digestive system, which includes the oesophagus, stomach, and duodenum.
▪ Its most common causes are peptic ulcers and gastritis.
▪ Its symptoms include hematemesis(vomiting of blood), melena (black stools) and
haematochezia (bright red or maroon-coloured stools).
▪ REGARDING MEDICATIONS:
▪ Take the prescribed medications on time.
▪ If missed, do not double the dose.
▪ Do not stop medications without counselling the doctor.
▪ Report any adverse reactions or side effects immediately .
▪ REGARDING LIFESTYLE MODIFICATIONS:
▪ Avoid trigger foods ( spicy, acidic, caffeine)
▪ Stay hydrated
▪ Quit smoking/ Alcohol consumption.
▪ Avoid NSAIDS like aspirin and ibuprofen.
▪ Manage stress.
CLINICAL PEARLS
▪ A duodenal ulcer is a common cause of upper gastrointestinal (UGI) bleeding,
characterized by the erosion of the lining of the duodenum, the first part of the small
intestine. This condition can lead to severe complications if not addressed promptly.
▪ When a duodenal ulcer bleeds, it can result in significant UGI bleeding, presenting
symptoms such as hematemesis (vomiting of blood), melena (black, tarry stools), or
hematochezia (fresh blood in stools).
▪ Prompt medical attention is crucial in managing UGI bleeding due to a duodenal ulcer.
Treatment typically involves stabilizing the patient, addressing any hemodynamic
instability, and identifying the source of bleeding through diagnostic procedures such
as upper endoscopy.
▪ Pharmacological therapy includes (e.g., proton pump inhibitors to reduce gastric acid
secretion), or in severe cases, surgical intervention.
CASE STUDY:
▪ Patient Profile: Name: John Smith Age: 65 years old Sex: Male Medical History:
Hypertension, Type 2 diabetes, Chronic kidney disease (stage 3), Previous history of
peptic ulcer disease
▪ Presenting Complaint: John Smith presents to the emergency department with
complaints of dark, tarry stools (melena) and dizziness for the past two days. He denies
any associated abdominal pain but reports feeling weak and lightheaded.
▪ History of Present Illness: Mr. Smith reports a gradual onset of melena, which started
two days ago. He denies any recent trauma, nonsteroidal anti-inflammatory drug
(NSAID) use, or alcohol consumption. He has not experienced any vomiting of blood
(hematemesis).
▪ Physical Examination: Vital Signs: Blood pressure 130/80 mmHg, pulse 100 bpm,
respiratory rate 18 breaths/min, temperature 37°C. General: Pale conjunctiva, otherwise
normal. Abdominal Examination: Soft, non-tender, no hepatosplenomegaly. Rectal
Examination: Positive for melena
▪ Laboratory Tests: Hemoglobin: 8.0 g/dL (baseline 12.0 g/dL)Hematocrit: 25%
(baseline 38%)Blood Urea Nitrogen (BUN): 30 mg/dL (normal range: 7-20
mg/dL)Creatinine: 1.8 mg/dL (baseline 1.2 mg/dL)Upper Endoscopy (EGD): Reveals
actively bleeding duodenal ulcer with visible vessel; epinephrine injection and
hemoclips applied for hemostasis.
▪ Diagnosis: Upper gastrointestinal bleeding secondary to a duodenal ulcer.
▪ Management: Initial Stabilization: Intravenous fluids, blood transfusion to maintain
hemoglobin > 7 g/dL, proton pump inhibitor (PPI) infusion. Endoscopic Intervention:
Successful endoscopic therapy with epinephrine injection and hemoclipping. Medical
Therapy: Initiation of intravenous PPI (pantoprazole).Follow-up: Close monitoring for
rebleeding, consideration for Helicobacter pylori testing and eradication therapy.
▪ Outcome: Mr. Smith's symptoms improve after endoscopic intervention and medical
therapy. He is discharged home with instructions for follow-up with gastroenterology
and primary care physicians.
THANKYOU