Gastrointestinal and hepatology · Moderate
This case is fictional and exists for study. It describes no real patient.
58 years · male
A 58-year-old male presents to the emergency department with a 12-hour history of vomiting dark blood and passing foul-smelling, black, tarry stools. He reports a 3-week history of worsening epigastric discomfort, for which he has been taking over-the-counter ibuprofen 400 mg three times daily for knee osteoarthritis. He has no past medical history of liver disease or alcohol excess. On examination, he appears lethargic and pale. Epigastric tenderness is present on palpation without guarding or rebound tenderness. Digital rectal examination confirms melena. Peripheral stigmata of chronic liver disease are absent.
Vital signs
- HR
- 112 bpm
- BP
- 94/62 mmHg
- RR
- 20/min
- Temp
- 36.8 °C
- SpO₂
- 96%
Examination findings
- Pale conjunctivae and cool extremities
- Epigastric tenderness without peritonitis
- Melena on digital rectal examination
- No palmar erythema, spider naevi, or gynecomastia
Investigations
| Haemoglobin | 7.8 g/dL | reference: 13.5-17.5 |
| Urea | 14.2 mmol/L | reference: 2.5-7.8 |
| Creatinine | 88 µmol/L | reference: 60-110 |
| Platelets | 215 10^9/L | reference: 150-400 |
Question 1 of 3
Which of the following is the most appropriate immediate management step?
The initial management of any haemodynamically unstable patient with acute upper GI bleeding follows an ABCDE approach. Establishing large-bore IV access (14G or 16G) and initiating IV crystalloid fluid resuscitation is the crucial first step. Option D (PPI) is not recommended prior to endoscopy in NICE guidelines and does not take priority over resuscitation. Option A (Blood transfusion) is required, but it is not the single first step: it cannot precede intravenous access, and crystalloid bridges the interval while blood is prepared. The restrictive threshold of 70 g/L (7.0 g/dL) in NICE NG24 applies only to patients who do not have major haemorrhage or acute coronary syndrome; this man is shocked with ongoing bleeding, and his haemoglobin lags his true losses until equilibration is complete, so urgent crossmatch — with group-specific or O RhD-negative blood if he cannot wait — and transfusion titrated to haemodynamic response should run alongside crystalloid resuscitation rather than await a value below 7.0 g/dL. Option C (Terlipressin and antibiotics) is indicated for suspected variceal bleeding, which is less likely here given the history of NSAID use and absence of liver disease stigmata.
Teaching point: In haemodynamically unstable acute upper GI bleeding, immediate fluid resuscitation via large-bore IV access precedes diagnostic or specific medical therapies.
Question 2 of 3
Which of the following is the most likely underlying diagnosis for this patient's presentation?
Peptic ulcer disease is the most common cause of acute upper GI bleeding. The patient's presentation with haematemesis, melena, epigastric pain, and heavy regular NSAID (ibuprofen) use strongly points toward NSAID-induced peptic ulceration. Option C is unlikely given the absence of chronic liver disease risk factors and exam findings. Option B typically follows repeated non-bloody retching or vomiting prior to haematemesis. Option A is possible in older adults, but acute severe bleeding with isolated short-term NSAID exposure makes PUD much more common.
Teaching point: Regular NSAID use is a major risk factor for peptic ulcer disease, the single most common cause of upper GI bleeding.
Question 3 of 3
Following initial resuscitation and stabilization, which investigation is the most appropriate next step?
NICE guidelines recommend early oesophagogastroduodenoscopy (EGD) within 24 hours of presentation for patients with acute upper GI bleeding once haemodynamically stabilized. EGD allows both diagnostic visualization and therapeutic intervention (e.g., clipping, thermal coagulation, injection). Option B (CT angiography) is used when endoscopy is unsuccessful, unavailable, or contraindicated. Option C (Barium study) is contraindicated in acute upper GI bleeding. Option D (Ultrasound) cannot visualize mucosal lesions of the stomach or duodenum.
Teaching point: Early endoscopy within 24 hours of admission is the gold-standard diagnostic and therapeutic investigation for acute upper GI bleeding once the patient is stabilized.
Key learning points
- Resuscitation with IV crystalloids via large-bore cannulae takes precedence over definitive diagnostic procedures in haemodynamically compromised GI bleeding.
- NSAID gastropathy leading to peptic ulcer disease is the primary aetiology of non-variceal upper GI bleeding.
- Early oesophagogastroduodenoscopy (EGD) within 24 hours provides definitive diagnosis and allows endoscopic haemostasis.
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