Presenting Complaint:

• Upper abdominal pain, haematemesis, and nausea and vomiting

Symptoms (SOCRATES):

• Site: Epigastric pain – “It’s just under my ribs, in the middle”
• Onset: Intermittent over the past few weeks – “It’s been coming and going for about a month”
• Character: Burning – “It feels like a burning pain”
• Radiation: Radiates to back – “It moves to my back”
• Associated symptoms: Nausea, acid reflux, vomited 1000 ml of blood-stained vomit this morning, feeling bloated – “Sometimes I feel sick after I eat and throw up. This morning a lot of blood came up too, about a litre”
• Time: Worse at night and when hungry – “It wakes me up sometimes, eating helps for a bit”
• Exacerbating/Alleviating factors: Worse on an empty stomach, better after eating or antacids – “Food and Gaviscon help a bit”
• Severity: Moderate – “It’s quite uncomfortable but not the worst pain ever”

Systemic Symptoms (answer only if specifically asked for):

• Urinary: Normal colour urine, normal frequency, no obvious blood
• Bowels: Noticed stool appeared dark and sticky
• Fever: No fever noticed
• Eyes: No abnormalities noted
• Weight loss: Mild weight loss, lost about 3kg recently because eating sometimes makes it worse
• Swallow: No dysphagia noted
• Chest: Chest pain intermittently, SOB on exertion noted  
• Syncope or LOC: None
• Night sweats: None
• Vomiting and nausea: Vomited blood once and feeling nauseous
• Fatigue: Increased levels of fatigue
• Pruritus: None

Past Medical History:

• Heartburn for years, never formally investigated
• Smoker for 20 years

Past Surgical History:

• None

Drug History:

• Over-the-counter antacids
• Occasional ibuprofen for back pain

Allergies:

• NKDA

Family History:

• No history of gastrointestinal cancer

Social History:

• Smoker: 15 cigarettes a day for 20 years
• Alcohol: 10 units per week
• Occupation: Construction worker, stressful job
• Diet: Often skips meals

Ideas, Concerns, and Expectations:

• Think it’s “just indigestion” 
• Worried it could be something worse because it wakes him at night and the blood in the vomit
• Wants a test to look for anything serious

Observations:

• Respiratory rate: 16
• Oxygen sats: 98% on room air
• Pulse: 120
• Blood pressure: 90/60
• Alert
• Temperature: 36.8

NEWS: 4

Examination:

General Inspection:

• Looks mildly uncomfortable
• No jaundice, looks slightly pale

Hands:

• No clubbing or tremor
• Capillary refill time 3 seconds
• Regular pulse, tachycardic
• No palmar erythema or Dupuytren’s contracture

Face:

• Conjunctival pallor present
• Dry mucous membranes

Neck:

• JVP not raised
• No scars or palpable lymphadenopathy

Chest:

• No spider naevi 

Abdomen:

Inspection

• No distension or scars

Palpation

• Epigastric tenderness with voluntary guarding
• Abdomen soft and mildly tender on palpation of the right/left lower quadrants
• No hepatomegaly or splenomegaly palpable
• No palpable renal or aortic masses
• No suprapubic tenderness

Percussion

• Normal, non-tender percussion

Auscultation

• Bowel sounds present, normal on auscultation

Special tests:

• Fluid thrill -> negative
• Murphy’s -> negative
• Rovsing’s -> negative
• If performed or asked for, melena noted on DRE
• Examination of external hernial orifices and genitalia normal

Other:

• No peripheral or sacral oedema

Laboratory Tests:

• Hb: 95 g/L (Normal Hb male range: 130–180 g/L)
  MCV: 72 fL (Normal MCV range: 80–100 fL)
• MCH: 25 pg (Normal MCH range: 27–32 pg)
• RDW: 15.8%  (Normal RDW range: 11.5–14.5%)
• Platelets: 420 x10⁹/L (Normal Platelets range: 150–400 x10⁹/L)
• Urea 11 mmol/L (Normal Urea range: 2.5 – 7.8 mmol/L)
• Creatinine 85 µmol/L (Normal Creatinine range: 60 – 110 µmol/L)
• Lipase 55 U/L (Normal lipase range: 10–140 U/L)
• Troponin T 0.014 ng/mL (Normal troponin T range: < 0.01-0.014 ng/mL)

12 lead ECG: 

• Rhythm: Sinus rhythm
• Rate: ~120 bpm (sinus tachycardia)
• P waves: Present, upright in leads I, II, aVF, precede each QRS
• PR interval: 0.16 s (within normal limits)
• QRS duration: 0.08 s (normal)
• Axis: Normal (approx. +60°)
• ST segments: Isoelectric in all leads (no elevation or depression)
• T waves: Upright in all leads except aVR and V1 (normal variant)
• QTc: 420 ms (normal)
• Additional findings: No pathological Q waves, no conduction delays, no arrhythmia

Examiner questions:

1. What is your main differential diagnosis and why is this more likely than other differentials?

Most likely differential: Peptic ulcer disease (PUD) with upper GI bleed

• Epigastric burning pain that is worse on an empty stomach, relieved by food and antacids, and on a background NSAID use and smoking is associated with peptic ulcer disease.
• Evidence of upper GI bleeding with haematemesis, malaena, raised urea and microcytic anaemia.
• The patient is haemodynamically unstable with evidence of hypovolaemic/haemorrhagic shock and requires immediate resuscitation.

Other differentials:

• Mallory Weiss tear is a differential with haematemesis and vomiting, however the chronic symptoms with epigastric pain related to eating and risk factors point towards peptic ulcer. This can be confirmed on endoscopy (OGD).
• Less likely to be ACS or pericarditis as ECG showed no abnormalities, troponin within normal range.
• Likely an element of underlying gastritis and gastro-oesophageal reflux disease (GORD), although the characteristic relationship of pain with eating here, and presence/suspicion of upper GI bleed (haematemesis, raised urea and anaemia) makes the diagnosis of peptic ulcer more accurate.
• Less likely to be functional dyspepsia as there is suspicion of peptic ulcer with upper GI bleed with anaemia, raised urea and haematemesis, pain radiating to the back.
• Less likely to be acute pancreatitis as normal lipase levels present.
• There are some concerning features which raise suspicion of malignancy (weight loss, abdominal pain, reflux, haematemesis), which although don’t quite meet NICE suspected cancer pathway referral criteria (new onset dysphagia, Aged >55 years with weight loss and either upper abdominal pain, reflux, or dyspepsia) are concerning. This can be assessed on endoscopy which will be performed due to the upper GI bleed.

2. State two complications of untreated peptic ulcer disease.

Possible answers: 

• Upper GI bleeding
• Perforation
• Gastric outlet obstruction
• Increased risk of stomach cancer

3. Name three risk factors that a patient may have that can predispose them to this condition

Possible answers: 

• Smoking
• NSAID use
• Corticosteroid use 
• Stress or irregular meals
• H. pylori infection
• Zollinger-Ellison syndrome
• Severe physiological stress: severe burns (Curling’s ulcer); head trauma (Cushing’s ulcer)

4. Describe the management of this condition

Possible answer: 

• Initial A-E assessment, including ECG, full set of bloods including amylase/lipase troponin (if required), FBC, U&Es, LFTs, Lactate, CRP, Glucose, Calcium profile, Coagulation screen and G&S, IV access, ABG/VBG.
• Resuscitation and supportive care including analgesia, goal-directed care with aggressive IV fluid resuscitation and circulatory optimisation, antiemetics, blood transfusion if required for anaemia or blood loss, correction of any underlying coagulopathy.
• Strict fluid balance and urine output monitoring with catheterisation.
• Test for H. pylori (breath test, stool test, endoscopic biopsy).
• Glasgow-Blatchford bleeding score (GBS) to identify whether the patient is ‘low-risk’ and upper GI bleeding could be managed in an outpatient setting, or will need inpatient endoscopy.
• Discussion between gastroenterologists, interventional radiology and surgical teams to decide management of bleeding peptic ulcer i.e. conservative vs radiological vs surgical.
• OGD to identify source of upper gastrointestinal bleeding.
• Rockall score post-endoscopy with findings, to identity severity of GI bleeding and associated mortality.
• Commence of PPI for 4-6 weeks with reassessment of symptoms afterwards.
• Consider Dietician input with nutritional support if prolonged NBM e.g. enteral feeding with NJ tube, TPN.
• Provide lifestyle advice if appropriate e.g. smoking cessation, reduction in alcohol, weight loss, diet, avoidance of NSAIDs.
• If positive for H. pylori treat with eradication triple therapy (PPI + amoxicillin + metronidazole/clarithromycin) for 7 days.