CASE 1

CHIEF COMPLAINT: "I'm passing black stool" and lightheadedness - 3 days.

HISTORY OF PRESENT ILLNESS: Mr. Murphy is a 45 year old advertising executive who presents to the
emergency room complaining of the passage of black stools x 3 days and an associated lightheadedness. He also
relates that he cannot keep up with his usual schedule because of fatigability. Upon further questioning he states
that his stools are not only black, but are sticky and malodorous. He further complains of recent worsening of a
chronic epigastric burning which had been a problem off/on for years. He had doubled his usual dose of turns
without significant relief of the burning. He has 2-3 martinis at lunch and another cocktail before dinner. He
takes NSAIDS as needed for back pain and recently started on one aspirin per day for cardiac prophylaxis. He
smokes two packs of cigarettes per day and an occasional cigar. He was told of an ulcer in the distant past but
had no specific evaluation or treatment for same.
Mr. Murphy has been treated for hypertension for eight years but denies any known cardiac history. His weight
is stable to increased and he claims to have an excellent appetite. He has a normal bowel habit and has not had
prior black stools. He has had no abdominal surgery and denies bleeding tendencies or prior transfusion.
PHYSICAL EXAMINATION: Examination reveals an alert, oriented, overweight male. He appears anxious
and somewhat restless. Vital sips are as follows. Blood Pressure 120/80 mmHg, Heart Rate 110/min Supine; BP 90/60 mmHg; HR Thready - Standing (Patient complains of dizziness upon standing). Respiratory
Rate - 20 /minute; Temperature 98 F.
HE-ENT/SKIN: Facial pallor and cool, moist skin are noted. No telangiectasia of the lips or oral cavity are
noted. No spider nevi are seen. The parotid glands appear full.
CHEST: Lungs are clear to auscultation and percussion. The cardiac exam reveals regular rhythm with an S4.
No murmur is appreciated. Peripheral pulses are present but are rapid and weak.
ABDOMEN/RECTUM: The abdomen reveals a rounded abdomen. Bowel sounds are hyperactive. There is
moderate tenderness in the epigastrium. The liver is percussed to 13 cm (mal); the edge feels firm. The spleen
was not felt and no masses were appreciated; the exam was felt to be suboptimal secondary to the patient's
obesity. Rectal examination revealed black, tarry stool.
There are no dupuytren's contractions.
LABORATORY TESTS: Hemoglobin 9gm/dL, Hematocrit 27%, MCV 90. WBC13,000/mm. PT/PTT normal. BUN 45mg/dL, Creatinine 1.0 mg/dL. Chest x-ray - normal. X-ray of abdomen (kidney, ureter, bladder
- KUB) is unremarkable.
1.Explainthesignificanceofthefollowingintheprotocolthatmyhaveabearingtothispatient'schief
complaint.Answer
History

Physical

Black stools.

Lightheadedness.

Sticky malodorous stools.

NSAID's.

Postural hypotension.

No telengiectasia.

No spider nevi.

Full Parotid glands.

Type of anemia.

BUN and Creatinine.

Lab

2.Whatisthemajorclinicalproblem(notthediagnosis)?Answer
3.Whatismostlikelycausefortheblackstoolsbasedontheinformationyouhavegatheredsofar?Answer
4.Whatphysicalfindingsandlabdatasupportadiagnosisofacutebleeding?Answer
5. WhatisthelikelylocationofbleedingsiteinGItractAnswer
6.Whatmakesthestoolbloodblack?Answer
7.Whatamountofbloodlossisrequiredtoproduceeachofthefollowing:Answer
8.Nowthatyouhavelocalizedtheprobableareaforableedingsourcedevelopadifferentialdiagnosisforthe
problem.Answer
9.Discussthelikelydiagnosis.Citedatatosupportyourdiagnosis.Describetheclinicalscenarioforother
diagnosisthatyouhavelistedaspossibilities.Answer
10.Nowthatyouhavethedifferential,whatarethehistoricalinformationthatyouwillgatherinevaluationof
acuteupperGIbleed?Answer
11.Whatphysicalfindingswillyoubelookingfor?Answer
12. PrioritizestepsthatwouldlikelybetakenintheERtotreatthispatient.Answer
13.AnasogastrictubewasplacedbytheERresident.Theaspiraterevealsaclearreturn.Whatdoesthismean?
Doesthischangeoralteryourdiagnosis?Answer
14.InterpretthepossiblereturnsfromnasogastrictubeAnswer
15.Whatwillbetheidealproceduretoconfirmthelocationofbleedingsiteandwhy?Answer

16.70/plus%ofUGIbleedswillceasespontaneously.WhatistheadvantageofdoingEGDinevery
case?Answer

17.ListfactorsthatincreasethemortalityandmorbidityfromUGIbleeding.Answer
18.Whataretheendoscopicfindingssuggestingincreasedriskforrebleeding?Answer

Explainthesignificanceofthefollowingintheprotocolthatmyhaveabearingtothispatient'schiefcomplaint.

Black stools.
o

Bloody (Upper GI bleeding): Tarry and sticky with fowl smell

Non-bloody

Therapeutic intake of iron

Pepto-Bismol (bismuth compounds)

Licorice.

Lightheadedness. A sign of low cardiac output secondary to hypovolemia.

Sticky malodorous stools. Not seen with non-bloody black stools.

NSAID's. Can give rise to Gastritis or precipitate bleeding from Ulcers.

Postural hypotension. A drop greater than 10 mm of Hg in erect position.

No telengiectasia. Finding indicating Hereditary hemorrhagic telengiectasia could be the etiology.

No spider nevi. Finding encountered in Cirrhosis suggesting possible esophageal varices as a

source of bleeding.

Full Parotid glands. Seen in chronic alcoholics with Cirrhosis.

Type of anemia. Normochromic anemia with acute bleed. Microcytic hypochromic anemia with
chronic bleed.

BUN and Creatinine. Absorption of GI blood and decreased renal perfusion,

2.Whatisthemajorclinicalproblem(notthediagnosis)?
Melena (tarry, black stools) is the major clinical problem
3.Whatismostlikelycausefortheblackstoolsbasedontheinformationyouhavegatheredsofar?

Acute GI bleeding

4.Whatphysicalfindingsandlabdatasupportadiagnosisofacutebleeding?

Manifestation of hypovolemia.
o

Anxiety, lightheadedness, restlessness.

Pale, moist skin.

Orthostasis, tachycardia

Weak peripheral pulses

Absorption of blood
o

Elevated BUN

Loss of blood
o

Decreased hemoglobin with normal MCV.

Melena per rectum.

5. WhatisthelikelylocationofbleedingsiteinGItract
Above the ligament of Treitz.
6.Whatmakesthestoolbloodblack?
HydrochloricacidconvertsHemoglobinto
Digestiveenzymesactuponthebloodandchangethecolorandconsistency.
7.Whatamountofbloodlossisrequiredtoproduceeachofthefollowing:

Occult positive stool. 3 cc (hemoccult).

Melena =100-200 cc

Orthostasis=20% loss of circulating volume or about 1000 cc.

8.Nowthatyouhavelocalizedtheprobableareaforableedingsourcedevelopadifferentialdiagnosisforthe
problem.

Duodenal ulcer

Gastric ulcer

Gastritis (Gastro-duodenal erosions)

Esophagitis (GERD)

Esophageal varices

Mallory-Weiss tear

Arteriovenous malformations

Swallowed blood from hemoptysis or orpharyngeal bleed

9.Discussthelikelydiagnosis.Citedatatosupportyourdiagnosis.Describetheclinicalscenarioforother
diagnosisthatyouhavelistedaspossibilities.
Bleedingduodenalulceristhemostlikelydiagnosis.

Diagnosis strengthened by epigastric burning with similar episodes in past.

Epigastric tenderness on exam.

The history of alcohol, smoking, NSAIDs use, aspirin use. (predisposing factors)

Prior history of "Ulcer"

Lightheadedness, orthostatic vitals. Cool, moist skin, Melena support acute GI bleeding

Elevated BUN. (Pre renal azotemia)

Gastroduodenalerosions.AbuseofNSAID
Esophagitis(GERD).Historyofreflux,
Esophagealvarices.Inacirrhoticwithportalhypertension.
MalloryWeisstear.Retchingfollowedbyhematamesis.
Arteriovenousmalformations.Inapatientwithstigmataforhereditaryhemorrhagictelengiectasia.
Swallowedbloodfromhemoptysisororopharyngealbleed
10.Nowthatyouhavethedifferential,whatarethehistoricalinformationthatyouwillgatherinevaluationof
acuteupperGIbleed?

Stool characteristics
o

Black

Sticky

Foul smell

Intake of
o

Iron

Pepto-Bismol (bismuth compounds)

Licorice

Symptoms of hypovolemia
o

Lightheadedness

Use of NSAID's. Can give rise to Gastritis or precipitate bleeding from Ulcers.

Epigastric distress

GERD symptoms

Retching

Nose bleeds

History of Alcoholism and Cirrhosis

Previous aortic surgery, portal hypertension

11.Whatphysicalfindingswillyoubelookingfor?

Manifestation of hypovolemia.
o

Anxiety, lightheadedness, restlessness.

Pale, moist skin.

Orthostasis, tachycardia

Weak peripheral pulses

Finding encountered in Cirrhosis suggesting possible esophageal varices as a source of bleeding.

o

Spider nevi.

Full Parotid glands

Ascites

Hepatomegaly

Splenomegaly

Hyperestrogenism

Finding indicating Hereditary hemorrhagic telengiectasia

Careful exam of Oropharynx for bleeding sites if any

12. PrioritizestepsthatwouldlikelybetakenintheERtotreatthispatient.

Briefhistory/physicalexam

Assessingthedegreeofcirculatorycompromisebydoingorthostatics.

EstablishIVaccesswith2largeboreIVs.

Volumereplacement.

Typeandcrossmatchforblood.

Nasaloxygen.

EKG.

LaboratoryevaluationtoincludeCBC,coags,BUN,creatinine.

Nasogastrictube.

Consultwithendoscopistandsurgicalcolleagues.

13.AnasogastrictubewasplacedbytheERresident.Theaspiraterevealsaclearreturn.Whatdoesthismean?
Doesthischangeoralteryourdiagnosis?

GIbleedingisoftentimesintermittentandcanstopspontaneously.

Theclearreturnsuggestsacompetentpylorusandbleedingcouldbestilloccurringinthebulb
andgoingpostbulbar.

14.Interpretthepossiblereturnsfromnasogastrictube

Coffeegrounds=slowbleedingoroozing.

Redblood/clots=activeongoingbleed.

Bilestained=noactivebleedingabovetheTreitzligament.AbilestainedNGaspiratewouldmake
activebleedingproximaltothethirdportionoftheduodenummostunlikely.

Clear=GIbleedingisoftentimesintermittentandcanstopspontaneously.Theclearreturn
suggestsacompetentpylorusandbleedingcouldbestilloccurringinthebulbandgoingpostbulbar.

15.Whatwillbetheidealproceduretoconfirmthelocationofbleedingsiteandwhy?

Oncethepatienthasstabilized(Noorthostasis,slowedpulse)anupperGIendoscopy
(EGD)wouldbetheprocedureofchoice.

EGDisdiagnosticandcanbetherapeuticifactivebleedingorvisiblevesselsareseen.

Injectiontherapywithepinephrineoravarietyofelectrocoagulationtechniquescanbe
usedtostopbleeding.

EGDinthiscaseswouldruleoutvarices(acauseofsevereUGIhemorrhages)whichwasan
initialconsideration.

AlsotheEGDcouldpermitabiopsytoevaluateforHelicobacterpylori,acausativeagentin
mostpepticdiseases.Abiopsywouldbetakenfromanareaoftheantrum,notfromorin
closevicinitytobleedinglesions.

16.70/plus%ofUGIbleedswillceasespontaneously.WhatistheadvantageofdoingEGDineverycase?

TheEGDcanprovideusefulinformation(diagnosis)aswellasbeingtherapeuticinneeded
instances.

Tissuecanbeobtained.

Theendoscopicfindingscanhelpassesstheriskforrecurrenthemorrhage(rebleeding
increasesmortality)

17.ListfactorsthatincreasethemortalityandmorbidityfromUGIbleeding.

Rebleedingafterinitialpresentation.

Severityindexofbleeding(transfusionrequirement,BRB/NGT,hypotension).

Varicealbleed

Age>60.

Multisystemdisease(comorbidity).

Endoscopicstigmataofrecentbleeding(Activebleeding,visiblevessels,freshclot).

Onsetofbleedinginhospitalizedpatient.

Needforemergencysurgeryforbleeding

18.Whataretheendoscopicfindingssuggestingincreasedriskforrebleeding?

Redspot/Ulcerbase10%

Clot20%

Visiblevessel50%

CleanbaseNegligible