pper Gastrointestinal (GI) Bleeding Due to Gastric Ulcer

Author: V. Dimov, M.D. Reviewer: S. Randhawa, M.D. A 68-year-old African American male (AAM wa! admitted to the ho!"ital with a chief com"laint (## of eme!i! of $ri%ht red $lood. &he "atient re"orted that he wa! !ho""in% when he $e%an throwin% u" $lood at the !tore. 'e denied any a!!ociated "ain, melena, hematoche(ia, liver di!ea!e, or "rior e"i!ode!. &he "atient re"orted !ome li%htheadedne!! with !tandin%, $ut denied che!t "ain (#) , !hortne!! of $reath (S*+ , and vi!ual di!tur$ance!. 'e had $een ta,in% indomethicin for %out and re"orted a recent admi!!ion - month! a%o for evaluation of occult $leedin%, with colono!co"y and u""er endo!co"y, which did not !how ulcer! or active $leedin%. &he "atient al!o denied a$dominal "ain, che!t "ain, cou%h and diarrhea. Past medical history (PMH) .out, hy"erten!ion ('&/ , anemia. &he review of medical record! !howed that he had a %out flare u" while in the ho!"ital - month! a%o and wa! di!char%ed home with a !teroid ta"er. 'e wa! "re!cri$ed indomethacin 01 m% "o 2 8 hr "rn "ain $ut he wa! ta,in% it daily for the la!t month. Stomach $io"!y done durin% the 3.D - month! a%o !howed acute and chronic inflammation, and a .iem!a !tain !howed occa!ional $acteria con!i!tent with 'elico$acter. A )AS4Alcian $lue !tain !howed no evidence of inte!tinal meta"la!ia. /o neo"la!m wa! identified. &he "atient mi!!ed hi! follow u" a""ointment and wa! never treated with anti$iotic! for 'elico$acter "ylori. Medications )revacid (lan!o"ra(ole , indomethicin. Family medical history (FMH) 'i! $rother died from .5 $leed la!t year. Physical examination Vital !i%n! (VS with ortho!tatic chan%e!. 3ye!: con6unctiva "ale, no icteru!. #he!t e7amination: #lear to au!cultation $ilaterally (#&A (+ . #ardiova!cular (#VS : #lear S8S9. A$domen: Soft, /&, /D, :+S. Rectal e7amination: no !tool. What is the most li ely diagnosis! ;""er .5 $leed due to: - )e"tic ulcer di!ea!e ();D - /SA5D!-induced %a!tro"athy What "ould suggest as the next step in his management! - .et 5V acce!! - .ive 5V< - /S 011 ml $olu! and then 901 ml4hr, monitor VS - #+#, #M), 5/R4)&& !tat &y"e and !creen = unit! of "ac,ed red $lood cell! ()R+# , tran!fu!e if hemo%lo$in i! $elow 8 m%4d>. #all .5 con!ult for emer%ency 3.D. Admit to 5#;. What happened! &he #+# !howed acute anemia with '%$ of 6 m%4d> (hi! '%$ wa! 81.? m%4d> three month! a%o . 5ntravenou! fluid! were %iven, and he wa! "laced on o7y%en and monitor. &he 3#. wa! inter"reted a! !inu! tachycardia. &he ri!,!, $enefit! and alternative! (R+A of $lood tran!fu!ion were e7"lained to the "atient and he a%reed to tran!fu!ion.

'emo%lo$in ('%$ decrea!e in u""er .5 $leed (clic, to enlar%e the ima%e .

+;/ increa!e in u""er .5 $leed (clic, to enlar%e the ima%e . What happened next! &he )atient wa! admitted to M5#;. &he 3.D !howed a $leedin% %a!tric ulcer which wa! cauteri(ed and the $leedin% !to""ed. 'e re2uired 9 more unit! of R+# and '%$ increa!ed to ?.1 m%4d>. )revacid 61 m% $olu! wa! %iven and he wa! "laced on )revacid 5V dri" at 6 m%4hr for @9 hour!. 'e wa! tran!ferred to a re%ular medical floor (RM< and clear li2uid! diet wa! !tarted. Anti$iotic treatment for 'elico$acter "ylori wa! !tarted $efore di!char%e. <eS*=, vit. # and MV& were al!o added. Final diagnosis ;""er .5 $leedin% due to %a!tric ulcer. 'i! %a!tric ulcer wa! !econdary to: - 'elico$acter "ylori infection - 5ndomethacin - Steroid! What did "e learn #rom this case! 'elico$acter "ylori infection need! to $e treated a%%re!!ively e!"ecially in "atient! with other ri!, factor! for );D !uch a! /SA5D! u!e. &hree re%imen! con!i!tently eradicate 'elico$acter (?1 "ercent when treatment duration i! 81 to 8= day!. &he treatment of choice i! tri"le thera"y with a "roton "um" inhi$itor, amo7icillin and clarithromycin for two wee,!. *ne e7am"le i! $%& A *me"ra(ole, Amo7icillin, #larithromycin. &he fir!t attem"t to eradicate '. "ylori fail! in 0 to 89 "ercent of "atient!. 'e#erences