Case 1


68 yo AAM is admitted to the hospital with chief complaint (CC): emesis of bright red blood.
Patient reports that he was shopping when he began throwing up blood at the store. He denies any
associated pain, melena, hematochezia, liver disease, or prior episodes. Patient reports some
lightheadedness with standing, denies CP, SOB, visual disturbances.


He is taking indomethicin for gout and reports a recent admission 3 months ago for evaluation of
occult bleed with colonoscopy and endoscopy which did not show ulcers or active bleeding. Patient
denies abdominal pain, chest pain, cough and diarrhea.


PMH:

Gout, HTN, anemia


Review of medical records show that he had a gout flare up while in the hospital 3 months ago and
was discharged home with a steroid taper. He was prescribed Indomethacin 50 mg po q 8 hr prn pain
but he was taking it daily for the last month.


Stomach biopsy done during the EGD 3 months ago showed acute and chronic inflammation, and a Giemsa
stain showed occasional bacteria consistent with Helicobacter. A PAS/Alcian blue stain showed no
evidence of intestinal metaplasia. No neoplasm was identified.


Patient missed his follow up appointment and was never treated with antibiotics for Helicobacter
pylori.


Medications:

Prevacid, indomethicin


FMH:

Brother died from GI bleed last year


Physical examination:

VS with orthostatic changes

Eyes: conjunctiva pale, no icterus

Chest: CTA (B)

CVS: Clear S1S2

Abdomen: Soft, NT, ND, +BS

Rectal: no stool


What do you think is going on?

Upper GI bleed due to:

- PUD

- NSAIDs-induced gastropathy


What would you do next?

Get IV access

Give IVF - NS bolys and then 250 cc/hr, monitor VS

CBC, CMP, INR/PTT stat


Type and screen 4U PRBC, transfuse if Hgb < 8.


Call GI consult for emergency EGD.


Admit to ICU


What happened?

CBC showed acute anemia with Hgb of 6 (Hgb was 10.9 three months ago).


Intravenous fluids were given, he was placed on oxygen and monitor.

ECG was interpreted as sinus tachycardia.


Risks, benefits and alternatives (RBA) of blood transfusion were explained to the patient and he
agreed to transfusion.


[LINK] [LINK]

Hgb drop in upper GI bleed


[LINK]

BUN increase in upper GI bleed


What happened next?

Patient was admitted to MICU.


EGD showed a bleeding gastric ulcer which was cauterized and bleeding stopped.


Patient required 2 more units of RBC and Hgb increased to 9.0.


Prevacid 60 mg bolus was given and he was placed on Prevacid IV drip at 6 mg/hr for 72 hours. He
was transferred to RMF and clear liquids diet was started.


Antibiotic treatment for Helicobacter pylori was started before discharge. FeSO4, vit. C and MVT
were also added.


Final diagnosis:

Upper GI bleeding due to gastric ulcer.


Gastric ulcer is secondary to:

- Helicobacter pylori infection

- Indomethacin

- Steroids


What did we learn from this case?

Helicobacter pylori infection needs to be treated aggressively especially in patients with other
risk factors for PUD like NSAIDs use.


Three regimens consistently eradicate Helicobacter (90 percent) when treatment duration is 10 to 14
days. The treatment of choice is triple therapy with a proton pump inhibitor, amoxicillin and
clarithromycin for two weeks. One example is OAC = Omeprazole, Amoxicillin, Clarithromycin. The
first attempt to eradicate H. pylori fails in 5 to 12 percent of patients.