Gastrointestinal · Year 2 · from Gastrointestinal
Case 1: Non-Variceal Upper GI Bleeding - Peptic Ulcer Disease
Patient Presentation
Demographics: 68-year-old male
Chief Complaint: Vomiting blood and black tarry stools for 1 day
History of Present Illness: The patient developed nausea and vomited approximately 500 mL of bright red blood mixed with clots this morning. He subsequently noticed black, tarry, foul-smelling stools. He reports epigastric discomfort for the past 2 weeks that he attributed to "indigestion." He felt lightheaded when standing and nearly fainted in the bathroom.
Past Medical History: Osteoarthritis (takes ibuprofen 800 mg three times daily for 3 months), hypertension, hyperlipidemia, coronary artery disease with prior stent (on aspirin 81 mg and clopidogrel)
Social History: Former smoker (quit 10 years ago), social alcohol (2-3 beers weekly)
Physical Examination
- Vital Signs: BP 92/58 mmHg (supine), HR 112 bpm; Standing: BP 74/50 mmHg, HR 138 bpm (positive orthostatic hypotension)
- General: Pale, diaphoretic male appearing anxious
- Abdomen: Soft, mild epigastric tenderness, no peritoneal signs, hyperactive bowel sounds
- Rectal Exam: Black, tarry, guaiac-positive stool
Workup and Results
- CBC: Hemoglobin 7.2 g/dL (baseline 13.5), Platelets 185,000
- BMP: BUN 48 mg/dL (elevated due to blood in GI tract), Creatinine 1.1 mg/dL
- Coagulation: PT/INR normal
- Type and Screen: Performed; 4 units PRBCs crossmatched
- Glasgow-Blatchford Score: 14 (high-risk; hemoglobin, BUN, blood pressure, melena all contribute)
- EGD (performed within 12 hours): Large 2-cm posterior duodenal ulcer with visible vessel (Forrest IIa) at the base; no active bleeding at time of endoscopy
Endoscopic image of a duodenal ulcer with evidence of recent hemorrhage. The visible vessel (Forrest IIa classification) at the ulcer base indicates high risk for rebleeding and requires endoscopic therapy.
Image Source: Wikimedia Commons. Samir, CC BY-SA 3.0
Diagnosis
Acute Upper GI Bleeding from Posterior Duodenal Ulcer (NSAID-induced) - Forrest IIa (High-Risk Stigmata)
Clinical Correlation
This case illustrates classic non-variceal upper GI bleeding from peptic ulcer disease, the most common cause of UGIB (30-40% of cases). Key teaching points include:
Risk Factor Analysis:
- NSAID use: Direct mucosal injury and prostaglandin inhibition reduce mucosal defense
- Dual antiplatelet therapy: Increases bleeding risk 3-5 fold when combined with NSAIDs
- Location: Posterior duodenal ulcers are particularly dangerous due to proximity to the gastroduodenal artery, which can cause massive hemorrhage if eroded
Clinical Presentation:
- Hematemesis: Frank blood indicates ongoing or recent active bleeding
- Melena: Black tarry stool from degraded blood (indicates at least 50-100 mL blood loss)
- Orthostatic hypotension: Indicates significant volume depletion (typically > 1L blood loss)
- Elevated BUN:Creatinine ratio: Blood protein absorbed in GI tract increases urea production
Forrest Classification and Rebleeding Risk:
- Forrest Ia (spurting): 55% rebleeding
- Forrest Ib (oozing): 43% rebleeding
- Forrest IIa (visible vessel): 43% rebleeding - requires therapy
- Forrest IIb (adherent clot): 22% rebleeding - consider clot removal and therapy
- Forrest IIc (flat pigmented spot): 10% rebleeding - no therapy needed
- Forrest III (clean base): 5% rebleeding - no therapy needed
Treatment
Resuscitation:
- Two large-bore IV access
- Crystalloid resuscitation (Lactated Ringer's)
- Restrictive transfusion strategy: Target hemoglobin 7-8 g/dL (not normal range)
- ICU admission given hemodynamic instability
Pre-Endoscopic Management:
- IV PPI: Pantoprazole 80 mg bolus followed by 8 mg/hour infusion
- Hold antiplatelet agents temporarily (discuss with cardiology)
- Consider erythromycin 250 mg IV to promote gastric emptying before EGD
Endoscopic Therapy (for Forrest IIa):
- Combination therapy preferred: Epinephrine injection (1:10,000) followed by thermal coagulation (bipolar) OR endoscopic clips
- Epinephrine alone is not sufficient (high rebleeding rates)
Post-Endoscopic Care:
- Continue high-dose IV PPI infusion (80 mg bolus + 8 mg/hour) for 72 hours
- Test for H. pylori (stool antigen or biopsy urease test)
- Transition to oral PPI twice daily after 72 hours
- NSAID cessation - if pain management needed, use acetaminophen or consider COX-2 selective agent with PPI if NSAID absolutely required
- Cardiology consultation regarding timing of antiplatelet resumption (typically resume aspirin within 3-5 days; rebleeding risk vs. stent thrombosis)