1. Clinical Case: Mr Veri Pushi: 45 year old married self-employed property developer You are present in casualty when this gentleman is brought in by ambulance at 2 am in the morning.

2. Clinical Case (2): You obtain a quick history from the ambulance officers, and then from his wife (who arrives shortly afterwards by car). His wife had found him collapsed in the toilet, confused and very pale. He had been complaining of abdominal discomfort just prior to the collapse, had vomited up some altered blood and passed some blackish-red diarrhoea.

3. Clinical Case (3): He had been celebrating the evening before with business associates after concluding the sale of one of his new retirement home developments. A considerable amount of alcohol had been drunk by the gentleman that evening and he had felt ‘rough’ when he arrived home 2 hours previously. His usual alcohol consumption is around 40-50 units of alcohol per week; he has been drinking at this level for the last 25 years.

4. Questions: What is likely to have occurred with this gentleman? What is the differential diagnosis? What are your management priorities?

5. Differential Diagnosis: Bleeding peptic ulcer: –Gastric / duodenal Bleeding oesophageal varices Mallory-Weiss syndrome (Oesophageal Tear) Haemorrhagic alcoholic gastritis Gastric neoplasm eroded bleeding vessel.

6. Management Priorities Good venous access. Quick assessment of bleed severity. Adequate blood samples Resuscitation of hypovolaemia and hypotension. Assessment of rebleeding risk: –Elderly / hypotensive on admission –Hb < 8 or H&M on admission

7. Important features to elicit from History & Examination: Features of hypovolaemia: pale, sweaty, pulse rate, BP. Previous ulcer disease, GI bleeds Concomitant medical conditions. Anticoagulation therapy. Previous or current liver disease, or risk factors for its development (alcohol, parenteral blood products, IV drug abuse etc). Stigmata of chronic liver disease. History suggestive of Mallory-Weiss tear?

8. Investigations: Laboratory: –FBC –Group & save / Xmatch (see below) –Clotting profile – If on anticoagulants, liver disease, platelets abnormal, multiple transfusions –U&Es, LFTs CXR: –When clinically indicated – –Cardiorespiratory disease / partial gastric volvulus ECC: –when clinically indicated.

9. His vital signs on admission were: BP 90 /50 mm Hg lying – unrecordable sitting. Pulse 130/min sinus tachycardia Respiratory rate 25/min Temperature 37.1 C JVP not detectable.

10. Patient stabilisation: Large bore cannulas inserted – blood taken. Resuscitation with volume expanders until blood is available “Haemaccel / Gelofusin” Packed red cells – used in conjunction. If hypotensive on admission – obtain surgical opinion. Arrange endoscopy – urgency depending on severity of bleed and local logistics.

11. Blood cross-match: 1 unit of blood for every 1g/dl that admission Hb below 10g/dL. PLUS: –4 units if patient is shocked on admission. PLUS: –2 units in reserve for a rebleed.

12. Monitoring management: BP & Pulse stabilised with resuscitation. Looking for rebleeding signs: –Fresh haematemesis / malaena in stabilised pt –Fall in BP rise in pulse in stabilised pt. –Fall in Hb of > 2g/dl in 24 hours

13. Unable to stabilise patient: Seek senior advice. Consider the need for repeat endoscopy Consider surgical intervention: Continued bleeding – esp spurting vessel. Rebleeding in hospital: 1 rebleed if > 60 years2 rebleeds if < 60 years High transfusion requirement: Age > 50 years4 units Age < 50 years6 units