Subinternship Medicine · Year 4 · from Subinternship Medicine

Case 3: Acute Gastrointestinal Bleeding with Hemodynamic Instability

Clinical Presentation

Patient Demographics: 62-year-old male

Chief Complaint: Large volume bloody stool

Clinical Context: You are the sub-intern on night float when you receive an urgent page: "Room 508, patient just had a large bloody bowel movement, BP dropping."

History of Present Illness: Mr. Chen is a 62-year-old male admitted 3 days ago for chest pain evaluation. Cardiac catheterization yesterday showed non-obstructive coronary artery disease, and he was started on aspirin and clopidogrel. He has been clinically stable until 10 minutes ago when he had a large maroon-colored bowel movement and felt lightheaded.

Past Medical History:

  • Hypertension
  • Type 2 diabetes
  • History of peptic ulcer disease (H. pylori treated 5 years ago)
  • Osteoarthritis

Medications:

  • Aspirin 81 mg daily (started 3 days ago)
  • Clopidogrel 75 mg daily (started yesterday)
  • Metoprolol 25 mg BID
  • Lisinopril 10 mg daily
  • Omeprazole 20 mg daily (started on admission)
  • Metformin 500 mg BID

Physical Examination:

  • Vital Signs: HR 118 bpm, BP 86/54 mmHg, RR 20/min, SpO2 98% on RA
  • General: Pale, diaphoretic, anxious
  • Cardiovascular: Tachycardic, thready peripheral pulses
  • Abdomen: Soft, mild epigastric tenderness, hyperactive bowel sounds
  • Rectal: Maroon stool, guaiac positive

Immediate Actions

Recognition: Class III hemorrhagic shock

  • Heart rate > 100
  • SBP < 90
  • Altered mental status (anxiety, confusion)
  • Estimated blood loss > 30%

ABCDE Stabilization:

  1. Airway: Patent
  2. Breathing: Adequate
  3. Circulation:
  • Two large-bore IVs (18G or larger)
  • Type and crossmatch for 4 units pRBCs
  • Initiate crystalloid bolus (1L NS wide open)
  • Activate massive transfusion protocol consideration
  1. Disability: Alert but anxious
  2. Exposure: Pale skin, no external bleeding

Immediate Orders:

  • STAT: CBC, CMP, coagulation studies, type and screen
  • Transfuse 2 units pRBCs (don't wait for hemoglobin result given hemodynamic instability)
  • IV pantoprazole 80 mg bolus, then 8 mg/hr infusion
  • Hold aspirin and clopidogrel
  • NPO
  • Place NG tube to assess for upper GI source
  • GI consultation for emergent endoscopy

Escalation Communication

Call to Senior Resident and Attending: "Mr. Chen in 508 is having an acute GI bleed with hemorrhagic shock. BP is 86/54, heart rate 118, he's pale and diaphoretic after a large maroon stool. He was just started on dual antiplatelet therapy after a cath. I've established two large-bore IVs, sent a type and crossmatch, started fluids, and I'm requesting emergent blood transfusion. I've also placed an NG tube - there's coffee-ground material, suggesting an upper source. I need you here and I'm paging GI for emergent EGD."

Workup Results

Laboratory Studies:

  • Hemoglobin 7.2 g/dL (admission: 13.8 g/dL)
  • Platelets 186,000/uL
  • INR 1.1
  • BUN 58 mg/dL, Creatinine 1.4 mg/dL
  • BUN/Cr ratio: 41 (elevated, suggesting upper GI bleed)

NG Tube Aspirate: Coffee-ground material, clears with lavage

Diagnosis

Primary Diagnosis: Acute upper gastrointestinal bleeding with hemorrhagic shock

  • Likely etiology: Peptic ulcer disease (reactivation in setting of dual antiplatelet therapy)

Glasgow-Blatchford Score: 14 (high risk, requires intervention)

Treatment Plan

Resuscitation:

  1. Transfuse to hemoglobin > 7 g/dL (> 8 if CAD symptoms)
  2. Correct coagulopathy if present
  3. Consider platelet transfusion if bleeding continues
  4. Continuous monitoring in ICU setting

Source Control:

  1. Emergent EGD within 12-24 hours (sooner if unstable)
  2. Endoscopic therapy as indicated (clips, epinephrine, cautery)

Post-Stabilization:

  1. Continue PPI infusion for 72 hours post-endoscopy
  2. Discuss with cardiology regarding antiplatelet therapy hold duration
  3. Test for H. pylori if ulcer confirmed

Clinical Image

Image Description: Upper GI bleeding commonly presents from peptic ulcer disease. Endoscopy reveals the source and allows therapeutic intervention.

Image Source: Radiopaedia - "Acute upper GI bleeding"

  • URL: https://radiopaedia.org/articles/acute-upper-gastrointestinal-bleeding
  • License: Educational use - Radiopaedia.org

Discussion Questions

  1. Early Recognition: In Case 1, what subtle signs might the nurse have noticed before the patient developed overt shock? How can you create a culture where nursing concerns are taken seriously?
  1. ABCDE Application: In Case 2, the patient has both respiratory and cardiac components to their distress. How does the ABCDE approach help you systematically address both?
  1. Escalation Decisions: In Case 3, at what point would you activate a rapid response team versus managing the situation with your immediate team? What factors influence this decision?
  1. Crisis Documentation: How would you document the acute events in each of these cases? What elements are essential for both clinical care and medicolegal protection?
  1. Team Communication: How would you debrief with the nursing staff after successfully stabilizing Case 1? What learning points would you highlight?

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