Clinical 

Case
REPORT

GI Rotation
September Batch 
OCT17-OCT30,2022
MENTOR: Dr.JACKLYN S0-CABAHUG
About the
Patient​
Identifying Data​

• 45  year  old male ​

• Advertising executive​
Chief complaint​
Passage of black stools x 3 days and
an associated lightheadedness with fatigueability
and weakness.
History of
Present Illness​
Patient developed easy fatigability and
generalized body weakness.​
His stools are not only black , but are sticky
and malodorous. ​
Recent worsening of a chronic epigastric
burning which had been a problem off/on for years. ​
  ​
​
History of
Present Illness​
​
He had doubled his usual dose of tums
without significant relief of the burning. ​
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.  ​
​
Past Medical
History​

Hypertension​
No history of coronary artery disease​
No abdominal surgeries​
Family Medical
History​
Unremarkable ​
Personal and Social History​

2-3 martinis at lunch and

another cocktail before
dinner ​
Review of
Systems​
No weight loss ​
Good appetite​
No easy bruisability  ​
​
​
Vitals examination
​
.
BP : 120/80 supine ​
BP : 90/60 standing ​(orthostatic hypotension)
HR : 110 ​(tachycardic)
RR : 20 ​
Temp : 36.9%​
02 sat : 95% room air​
General
Survey: ​ ​
​ Alert, oriented, overweight male​

.​ Anxious and somewhat restless ​

Anicteric sclera, pale palpebral conjunctiva ​
No active dermatoses, cool extremities​
​
​
Symmetrical chest expansion, clear breath sounds ​
Distinct heart sounds, regular rhythm, no audible murmurs​
Peripheral pulses are present but are rapid and weak ​
​
​
​
​
​
Abdomen: ​
Flat abdomen, soft, with direct tenderness in
the epigastric area and the left upper quadrant ​
Hyperactive bowel sounds​
No palpable​
No guarding or rebound tenderness​
Liver not enlarged​
Spleen not palpable, no masses appreciated​
​
​
​
Rectal: ​
Good sphincteric tone, ​
No palpable masses​
Black tarry stool ​
No motor or sensory deficits ​
​
​
​
​
​
 Hemoglobin 9gm/dL, ​
Hematocrit   27%, ​
CBC: ​ MCV 90, ​
WBC 13 ​
PT/PTT – normal​

BUN 45mg/dL ​

Creatinine 1.0 mg/dL ​

Lab findings
Chest x-ray – normal ​

X-ray of abdomen (kidney, ureter, bladder - KUB) is

unremarkable. ​
Salient Features​
• Black tarry stools (Sticky and malodorous ) x 3
days .
• Lightheadedness.​
• Easy fatigability and generalized body weakness.​
• Worsening of a chronic epigastric burning which
had been a problem off/on for years. ​
• Smokes two packs of cigarettes per day and an
occasional cigar​
Salient Features​
• Takes NSAIDS as needed for back pain ​
• Recently started on one aspirin per day for
cardiac prophylaxis ​
• 2-3 martinis at lunch and another cocktail before
dinner
• Overweight, anxious and restless.
• Tenderness in epigastric area ​
Initial
Impression ​

Melena secondary to UGIB​

Physical
Examination
Findings ​
• Change of BP from 120/80 mmHg to
90/60 mmHg standing (Orthostatic Hypotension)
:  blood loss in stool​
• HR of 110 due to hypovolemia (blood in stool)​
• Anxious and somewhat restless due
to dehydration and anemia​
Physical
Examination
Findings ​
• Cool extremities due to vasoconstriction due to blood loss​
• Pale palpebral conjunctiva due to anemia​
• Weak and rapid peripheral pulses as a result of blood loss
(hypovolemia)​
• Tenderness in the epigastric and left upper quadrant shows
upper GI pathology ​
• Hyperactive bowel sounds and black tarry stool suggests
UGIB​
​
Other PE findings unremarkable ​
Lab findings ​
• Hemoglobin of 9gm/dl  (12-15 g/dL) : indicates anemia ​
• Hematocrit of 27% (36-44%) : decreased red blood cells
due to UGIB​
• WBC 13 (4-11x109/L) : suggests infection ​
• BUN 45 mg/dl (6-24 mg/dl): due to volume depletion
and blood proteins absorbed in the small intestine ​
• MCV 90,  PT/PTT, Creatinine, Chest and Abdomen X-
ray: Normal ​
​
​
1) RULE-IN RULE-OUT
Ruptured Eso Black tarry stools Liver,  spleen
phageal Varic and abdominal 
examination
es​ normal

History of  PT normal

alcohol intake 

Tachycardia 
2)Mallory-
Weiss Tear
RULE-IN RULE-OUT
Black tarry stools Chronic worsening of epigastric
pain

History of alcohol intake  (-) Emesis 

Epigastric pain  (+) Hypovolemic state

Needs endoscopy to r/o

completely 
3)EROSIVE
GASTRITIS
RULE-IN RULE-OUT
Black tarry stools (+) Good appetite

History of smoking and (-) Weight loss 

alcohol intake 
(-) Bloating 

Epigastric pain  Need endoscopy to

r/o completely
History of
taking NSAIDS 
3 Gastric                   RULE-IN          RULE-OUT
adenocarcino
ma  Black tarry stools  (+) Good appetite

History of smoking (-) Weight loss 

Epigastric pain Normal

abdominal examination
Easy fatigability  Needs endoscopy
and biopsy to
completely rule out 
Generalized body weakness 
4) Peptic ulcer
disease                         RULE-IN          RULE-OUT

Black tarry stools  NONE

Epigastric pain 

Anemia

Chronic on and off pain

History of aspirin and NSAIDS use

 UGIB secondary to Peptic
Diagnosis ​ Ulcer Disease secondary
to NSAIDS use​
Types of GI
bleeding ​
Based on
presentation ​
Overt​ Occult ​
Overt GIB is manifested Symptoms of blood loss
by hematemesis, vomitus of or anemia such
red blood or “coffee-grounds”​
as lightheadedness, synco
material​
melena, black, tarry stool​
pe, angina, or dyspnea;
 and/or hematochezia, passage or with iron-
of red​ deficiency anemia or a
or maroon blood from the positive fecal occult blood
rectum. ​ test on routine testing​.
​
Based on site of
bleeding ​
• UGIB (esophagus, stomach,​
duodenum)​

• LGIB (colonic)​

• Obscure GIB (if the​

source is unclear)​
​
​
Causes of UPPER GI bleeding ​

Peptic Ulcers​
Esophageal varices​

Mallory-Weiss tears​ Erosive disease​

 UPPER GI bleeding 

​
PEPTIC ULCERS:​
Peptic ulcers are the most common cause of  UGIB, accounting for ~50%
UGIB hospitalizations.​
Caused by H.pylori and long term use of NSAIDs.
​
MALLORY-WEISS TEARS:​
Accounts for ~2-10% of UGIB hospitalizations.​
The classic history is vomiting, retching or coughing preceding
hematemesis, especially in an alcoholic patient​.
Caused by binge drinking leading to sub mucosal tear.
​
 UPPER GI bleeding 

ESOPHAGEAL VARICES:​
The proportion of UGIB hospitalizations due to varices ranges widely from ~2-40%.​
Patients with variceal hemorrhage have poorer outcomes than patients with
other sources of UGIB.​
​
EROSIVE DISEASE\ DRUG INDUCED GASTRITIS :​
Erosions are endoscopically visualized breaks which are confined to the mucosa and
do not cause major bleeding due to the absence of arteries and veins in the mucosa.​
Caused by the use of COX1 inhibitors.
CAUSES OF LOWER GI BLEEDING​

Neoplasm Crohn’s disease​

Meckel’s diverticulum Polyposis syndromes
Pathophysiology NSAID use

COX 2 COX 1 inhibition Topical

inhibition irritation

↓ Prostaglandins

↑ H+ production 
↓ gastric mucous production and HCO3-
Neutrophil activation,
↑ Leukocyte adhesion,
Erosion of mucosa Epithelial damage
Inhibits cell healing,
↓ Epithelial cell renewal
Infection Erosion into blood vessel
 ↓ hematocrit
↑ WBC
BLEEDING ANEMIA
↓ hemoglobin
Blood passes
Breakdown of blood proteins through GI tract,
(hemoglobin, immunoglobulins) becomes oxidised
by HCl & digestion ●Pale palpebral conjunctiva
●Lightheadedness
MELENA ●Easy fatigability
↑ BUN ●Generalised body weakness
Black, sticky, malodorous stool
Management based on endoscopic findings
Diagnostic Modalities ​
UGIB​

• Upper Endoscopy

• Blood tests(CBC)
Small intestine ​

• Angiography​

• Push enteroscopy

• CT enterography
• Video capsule
endoscopy
LGIB ​

• Colonoscopy

• Flexible sigmoidoscopy

• CT Angiography
• Imaging tests

• Fecal occult blood
Management of
active GI
bleeding
Assess hemodynamic stability​
Resuscitation ​
Intravenous fluids​
Intravenous PPI​
+/- blood transfusion ​

● ​ pper Endoscopy
U
● Medical management 
● If still bleeding surgical management
​
Prevention of
recurrent
bleeding:​
​
H.pylori eradication ​
Stop NSAID and aspirin use​
Indefinite PPI therapy ​
References​

Harrison’s
Principles of
Google images
Internal Medicine
20th edition ​
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