Internal Medicine · Year 3 · from Internal Medicine
Case 1: Upper GI Bleeding - Peptic Ulcer Disease
Patient Presentation
A 58-year-old man presents with one episode of vomiting bright red blood followed by several episodes of maroon-colored stools over the past 6 hours. He reports epigastric pain for the past 2 weeks that he has been treating with ibuprofen. He has a history of osteoarthritis and takes daily ibuprofen and low-dose aspirin for cardiovascular protection. He denies alcohol use.
Vital Signs
- Blood Pressure: 92/58 mmHg
- Heart Rate: 118 bpm
- Respiratory Rate: 20/min
- Oxygen Saturation: 97% on room air
- Temperature: 36.8°C
- Orthostatic changes: Yes (HR increases 30 bpm when standing)
Physical Examination
- General: Pale, diaphoretic, anxious
- Cardiovascular: Tachycardic, regular rhythm
- Abdomen: Soft, mild epigastric tenderness, no guarding or rigidity
- Rectal exam: Maroon stool, guaiac positive
Initial Workup
- Hemoglobin: 7.2 g/dL (baseline unknown)
- Platelets: 245,000/μL
- BUN: 42 mg/dL
- Creatinine: 1.1 mg/dL
- INR: 1.0
- Type and screen: Ordered
Clinical Image
Figure 1: Endoscopic image of a bleeding gastric ulcer with a visible vessel (Forrest classification Ia - active spurting), requiring urgent endoscopic intervention.
Image Source: Educational illustration for teaching purposes.
Questions
- What is this patient's Glasgow-Blatchford Score (GBS) and what does it indicate?
- A) Low score indicating possible outpatient management
- B) High score indicating need for intervention
- C) Score used only for lower GI bleeding
- D) Score used only after endoscopy
- What are the priorities of initial resuscitation?
- A) Immediate endoscopy
- B) IV access, fluid resuscitation, blood transfusion, monitoring
- C) CT angiography
- D) Oral PPI therapy
- When should endoscopy be performed in upper GI bleeding?
- A) Within 48 hours for all patients
- B) Emergent (<12 hours) if hemodynamically unstable; within 24 hours for most patients with UGIB
- C) Only after complete bowel prep
- D) After 72 hours of PPI therapy
- What is the role of proton pump inhibitors in UGIB?
- What is the Forrest classification and how does it guide management?
Answers
- B) High score indicating need for intervention - The Glasgow-Blatchford Score uses admission data (BUN, hemoglobin, systolic BP, heart rate, presence of melena/syncope, hepatic disease, cardiac failure) to predict need for intervention. This patient has elevated BUN, low hemoglobin, tachycardia, hypotension, and melena - indicating high risk.
- B) IV access, fluid resuscitation, blood transfusion, monitoring - Initial management:
- Two large-bore IV lines
- Crystalloid resuscitation
- Packed RBCs if hemoglobin <7 g/dL (or <8 in cardiovascular disease)
- Correct coagulopathy if present
- ICU monitoring if hemodynamically unstable
- B) Emergent (<12 hours) if hemodynamically unstable; within 24 hours for most patients with UGIB - Urgent endoscopy (<24 hours) is standard for UGIB. Emergent endoscopy (<12 hours) is indicated for persistent hemodynamic instability despite resuscitation.
- Role of PPIs in UGIB:
- High-dose IV PPI (pantoprazole 80 mg bolus, then 8 mg/hour infusion) after endoscopy for high-risk ulcers
- Reduces re-bleeding, need for surgery, and mortality
- Pre-endoscopic PPI may downstage lesions but does not improve mortality
- Transition to oral PPI after 72 hours of IV therapy
- Continue PPI therapy long-term for peptic ulcer disease
- Forrest classification:
- Ia: Active spurting - 90% re-bleed risk - needs endoscopic therapy
- Ib: Active oozing - 50% re-bleed risk - needs endoscopic therapy
- IIa: Visible vessel - 43% re-bleed risk - needs endoscopic therapy
- IIb: Adherent clot - 22% re-bleed risk - consider removing clot
- IIc: Flat pigmented spot - 10% re-bleed risk - no endoscopic therapy
- III: Clean base - <5% re-bleed risk - can feed, consider discharge