• Mr Veri Pushi:
• 45 year old married self-employed
• You are present in casualty when this
gentleman is brought in by ambulance at 2
am in the morning.
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
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.
• What is likely to have occurred with this
• What is the differential diagnosis?
• What are your management priorities?
• Bleeding peptic ulcer:
– Gastric / duodenal
• Bleeding oesophageal varices
• Mallory-Weiss syndrome (Oesophageal Tear)
• Haemorrhagic alcoholic gastritis
• Gastric neoplasm eroded bleeding vessel.
• Good venous access.
• Quick assessment of bleed severity.
• Adequate blood samples
• Resuscitation of hypovolaemia and
• Assessment of rebleeding risk:
– Elderly / hypotensive on admission
– Hb < 8 or H&M on admission
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
• Stigmata of chronic liver disease.
• History suggestive of Mallory-Weiss tear?
– Group & save / Xmatch (see below)
– Clotting profile – If on anticoagulants, liver disease,
platelets abnormal, multiple transfusions
– U&Es, LFTs
– When clinically indicated –
– Cardiorespiratory disease / partial gastric volvulus
– when clinically indicated.
His vital signs on admission were:
• BP 90 /50 mm Hg lying – unrecordable
• Pulse 130/min sinus tachycardia
• Respiratory rate 25/min
• Temperature 37.1 C
• JVP not detectable.
• 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
• Arrange endoscopy – urgency depending on
severity of bleed and local logistics.
• 1 unit of blood for every 1g/dl that
admission Hb below 10g/dL.
– 4 units if patient is shocked on admission.
– 2 units in reserve for a rebleed.
• 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
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 years 2 rebleeds if < 60 years
High transfusion requirement:
Age > 50 years 4 units
Age < 50 years 6 units