GI Emergencies: Case #1

25 year old woman presents with hematemesis after having consumed two beers. PMH: bacterial vaginosis Meds: Metronidazole (since yesterday) HPI: Drank 2 beers, felt nauseated, forcefully vomited twice, then noticed a streak of red blood in emesis after vomiting a third time. No abdo pain or abnormal stool colour. Feels well now. HR 78, BP 126/82, RR 16, Sat 99% RA, T36.8po DRE reveals brown OB negative stool Exam: otherwise unremarkable. Labs: CBC & SMA7 are within normal limits, BHCG is negative

1) What is your differential diagnosis for hematemesis, and what is the most likely cause of this patient’s hematemesis?

2) How can you identify patients with hematemesis who are very unlikely to require endoscopic intervention, and can be safely discharged home?

GI Emergencies: Case #2 78 year old man presents with two episodes of passing black tarry stool today. PMH: stable CAD, HTN, DLP Meds: ASA, metoprolol, atorvastatin HPI: As above. Denies nausea/vomiting and abdominal pain and feels otherwise well. He had some low back pain a few days ago (after heavy lifting), which is now resolved. He had taken three doses of diclofenac for this pain. HR 78, BP 126/82, RR 16, Sat 99% RA, T36.8po DRE: black tarry stool, strongly OB positive Exam: otherwise unremarkable Labs: normal except Hg 82 and urea 12

1) What is the most likely diagnosis? 2) Should this patient have an NG inserted? 3) Should this patient be transfused? 4) Are there any medications you can give him that will reduce his mortality? 5) How can you stratify his risk of poor outcome after endoscopy?

GI Emergencies: Case #3 50 year old male presents acutely after two episodes of hematemesis. PMH: Remote cholecystectomy. Has not seen MD in > 20 years Meds: none Habits: 12 beer + half bottle wine/day x many years HPI: As above. He complains of vague longstanding abdominal discomfort and increasing girth with no recent change. He has not noticed his stool colour. His last drink was six hours prior to presentation. HR 112, BP 106/68, RR 22, Sat 95% RA, T36.8po DRE: brown OB + stool Exam: Alert, oriented x 3. Pale, anxious appearance with tremulousness. H&N: pale conjunctiva, no scleral icterus, bilateral parotid gland enlargement. Chest/CVS exams normal. Abdomen distended with fluid wave and mild diffuse tenderness. Prominent collateral veins on abdomen. Labs: Hg 94 with elevated MCV, platelet count 88, WBC normal. INR 1.9. SMA7 normal except K 3.2, urea 14, creatinine 124. LFT’s slightly elevated, lipase normal.

1) What are the concerning features of this case? 2) What do you think is the cause of his hematemesis? 3) How would you manage this case?

GI Emergencies: Case #4

68 year old female with left sided abdominal pain and hematochezia. PMH: ESRF on hemodialysis, DM, CAD (discharged 5 days ago after NSTEMI with stent), PVD Meds: ASA, plus a huge list that doesn’t matter right now HPI: She went home from her hemodialysis session a few hours ago, returning with a gradual onset of moderate left sided abdominal pain followed by an episode of hematochezia. She feels weak and nauseated but did not vomit. HR 112, BP 96/54, RR 22, Sat 95% RA, T36.8po DRE: Maroon OB positive stool Exam: Abdomen is soft but tender in the left upper and lower quadrants, and mildly distended with normal bowel sounds. Rest of exam non-contributory. Labs: Hb 69, WBC 18.8, plt 225. SMA7 normal except bicarb 16.

1) What etiologies do you consider in patients with hematochezia? 2) What do you think is going on in this patient? 3) What further work-up would you want to do in this patient? 4) How would you treat this patient?