1.Click toedit Mastertitle styleContinous Medical Education (CME)Md Azhari HOSPITAL KAJANG

2. Click toeditClinical CaseMastertitle style 68 / C/ Gentleman is admitted to the hospital withCC: emesis of bright red blood. Patient reports that he was shopping when hebegan throwing up blood at the store. He denies anyassociated pain, melena, hematochezia, liverdisease, or prior episodes. Patient reports some lightheadedness withstanding, denies CP, SOB, visual disturbances. He is taking indomethicin for gout. Patient deniesabdominal pain, chest pain, cough and diarrhea. 3. Click to editMaster title style PMHx:Gout, HTNHe had a gout flare up while in the hospital 3 monthsago and was discharged home with a steroid taper. Hewas prescribed Indomethacin 50 mg po q 8 hr prn painbut he was taking it daily for the last month. PSHX: Nil Allergic Hx : NKA FAMILY Hx : Gout 4. Click to editMaster title style Physical examination: Alert and Concious, Lethargic, no stigmata of chronic liver disease Vital sign : BP 104/70 PR-104 RR-26 T-37 Eyes: conjunctiva pale, no icterus Chest: Clear CVS: DRNM Abdomen: Soff NT, No Organomegaly, +BS Rectal: no stool 5. Click to editMaster title styleDiagnosis?? 6. Click toedit Mastertitle style UPPERGASTROINTESTINALBLEEDING 7. Click toeditUpper Gastrointestinal Mastertitle styleBleeding UGIB Bleeding from esophagus, stomach orduodenum (Proximal to the Ligament of Treitz) Presentation Sx Anemia Haematemesis Coffee ground emesis Melena Hematochezia Hypovolumia & shock Nonspecific complaint ( dypsnea, abdominal cramps, chestpain & fatigue) 8. Click toCAUSES %edit Mastertitle stylePEPTIC ULCER 50MUCOSAL LESION (GASTRITIS, 30DUODENITIS)MALORY WEISS TEAR5-10VARICES5-10REFLUX ESOPHAGITIS5 9. Click toedit MasterDifferential Diagnosestitle styleEsophagus GastricDuodenum SystemicVarices UlcerUlcerLeukamiaEsophagitis GastritisAotoenteric Fistula HemophiliaTumourGastric VaricesErosion of the Thrombocytopenia Pancreatic tumorTumor(malignant & Coagulopathybenign)Dieulafoys LesionHereditaryHemorrhagicTelangiectasiaMallory Weiss Tear 10. Click toedit MasterPeptic Ulcer Diseasetitle style Duodenal ulcer epigastric pain, relieved by eating Gastric ulcer epigastric pain, may precipitated byfood Exacerbation factors stress, smoking, alcohol,NSAIDS, steroids, hyperparathyroidism, Zollinger-Ellison syndrome Diet history*A perforated Ulcer Rarely Bleed And A bleeding Ulcer Rarely Perforates 11. Click toedit MasterEsophageal Varicestitle style Portal hypertension Chronic liver disease Social history alcohol Hemorrhoids, ascites, bleeding tendency Stigmata of chronic liver disease 12. Click toedit Mastertitle style 13. Click to editResuscitation Master title style Airway- secure the airway- Intubate if necessary- Prevent risk of aspiration pneumonia Breathing - give supplemental oxygen- Monitor SpO2 > 96% 14. Click to editMaster title style Circulation-Insert 2 large bore branula (16G) on each arm.-Consider CVP line in elderly with profound shock andsignificant comorbid.-Do blood i(x) for : FBC, LFT, clotting profile, GXM,BUSE and creatinine, Glucose level.-Give crystalloid (Normal Saline, Hartman).-Give colloid infusion (Gelofusil) if in shock.-Monitor vital signs. Do baseline ECG in elderly. 15. Click toedit MasterInvestigationstitle style FBC- Hb, platelet Coagulation profile RP LFT GXM Endoscopy ECG Chest X-ray 16. Click to editMaster title styleBlood transfusion should be given if:- systolic BP < 110 mmHg.- Significant postural hypotension.- Persistent tachycardia >110/min- Initial Hb < 8g/dL- Hb < 10 g/dL + CVs Disease Give FFP if INR >1.5 or PT is prolonged. Transfuse platelet if