Gastrointestinal · Year 2 · from Gastrointestinal
Case 1: Peptic Ulcer Disease with Upper GI Bleeding
Patient Presentation
Demographics: 58-year-old male
Chief Complaint: Black tarry stools and lightheadedness for 2 days
History of Present Illness: The patient noticed black, tarry, foul-smelling stools (melena) starting 2 days ago. He has had mild epigastric discomfort for several weeks that he attributed to "indigestion." Today he felt lightheaded upon standing and nearly fainted. He denies hematemesis. He has been taking ibuprofen 600 mg three times daily for knee pain for the past 3 weeks.
Past Medical History: Osteoarthritis, hypertension
Medications: Ibuprofen, lisinopril, aspirin 81 mg daily
Social History: Occasional alcohol use, non-smoker
Physical Examination
- Vital Signs: BP 98/62 mmHg (supine), 78/50 mmHg (standing); HR 108 bpm (supine), 128 bpm (standing)
- General: Pale, diaphoretic male
- Abdomen: Mild epigastric tenderness, no peritoneal signs
- Rectal: Black, tarry stool, guaiac positive
Workup and Results
- CBC: Hemoglobin 7.2 g/dL (baseline 14), MCV 82 fL, platelets 285,000
- BMP: BUN 42 mg/dL, Cr 1.1 mg/dL (elevated BUN:Cr ratio suggests upper GI bleeding)
- Upper Endoscopy: 1.5 cm posterior duodenal bulb ulcer with visible vessel (Forrest IIa), no active bleeding
- H. pylori: Positive on biopsy urease test
Endoscopic image of a posterior duodenal ulcer with a non-bleeding visible vessel (Forrest IIa), a high-risk stigmata indicating significant rebleeding risk without endoscopic therapy.
Image Source: Wikimedia Commons, CC BY-SA 3.0
Diagnosis
NSAID-induced and H. pylori-associated Posterior Duodenal Ulcer with Upper GI Bleeding
Clinical Correlation
Peptic ulcer disease results from an imbalance between aggressive factors (acid, pepsin, NSAIDs, H. pylori) and protective factors (mucus, bicarbonate, prostaglandins, mucosal blood flow). NSAIDs inhibit cyclooxygenase, reducing prostaglandin synthesis and compromising mucosal defenses. H. pylori infection causes chronic inflammation. Posterior duodenal ulcers are particularly dangerous because they can erode into the gastroduodenal artery, causing massive hemorrhage. The Forrest classification guides treatment: a visible vessel (IIa) carries ~40% rebleeding risk without therapy.
Treatment
- IV PPI bolus (80 mg) followed by continuous infusion (8 mg/hour for 72 hours)
- Endoscopic therapy: combination of epinephrine injection plus clip application to visible vessel
- Blood transfusion targeting hemoglobin 7-8 g/dL (restrictive strategy)
- Discontinue NSAIDs and aspirin (discuss with cardiology regarding aspirin)
- H. pylori eradication: bismuth quadruple therapy for 14 days
- Confirm eradication with urea breath test or stool antigen 4+ weeks after treatment