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 two-day history of vomiting dark, coffee-ground material and passing black, tarry stools. He reports feeling lightheaded when standing up. His past medical history is significant for osteoarthritis, for which he has been taking high-dose over-the-counter ibuprofen daily over the past month without a proton pump inhibitor. He drinks 10 units of alcohol weekly. On examination, he appears pale and diaphoretic. Abdominal examination reveals mild epigastric tenderness without guarding or rebound. Digital rectal examination confirms melena. Initial blood work demonstrates a significant drop in haemoglobin and an elevated urea level with normal creatinine.
Vital signs
- HR
- 118 bpm
- BP
- 88/56 mmHg
- RR
- 22/min
- Temp
- 36.8 °C
- SpO₂
- 96%
Examination findings
- Pallor and diaphoresis
- Epigastric tenderness on deep palpation
- Melena present on digital rectal examination
Investigations
| Haemoglobin | 7.2 g/dL | reference: 13.5-17.5 |
| Urea | 15.4 mmol/L | reference: 2.5-7.8 |
| Creatinine | 82 µmol/L | reference: 59-104 |
| Platelets | 210 10^9/L | reference: 150-400 |
Question 1 of 3
Which of the following best explains the disproportionately elevated blood urea level relative to serum creatinine in this patient?
Upper GI bleeding delivers a large protein load (haemoglobin and serum proteins) to the small intestine, where it is digested and absorbed, leading to increased hepatic urea production. Acute tubular necrosis (option B) would elevate serum creatinine alongside urea. Impaired hepatic urea synthesis (option D) would lower, not raise, serum urea. NSAIDs can cause renal injury, but that would elevate creatinine as well (option A).
Teaching point: An isolated elevation of blood urea with a normal creatinine is a classic biochemical indicator of upper gastrointestinal bleeding due to digestion of luminal blood proteins.
Question 2 of 3
Which of the following is the most appropriate initial management step for this patient?
The patient is haemodynamically unstable (hypotensive and tachycardic). Immediate management must focus on resuscitation (ABCDE approach) using IV crystalloids and blood products to restore volume before definitive interventions. Tranexamic acid (option A) is not routinely recommended for acute upper GI bleeding per UK NICE guidelines. Endoscopy (option D) is required within 24 hours, but only after initial haemodynamic stabilization. Oral PPIs (option B) are inappropriate in an unstable patient with active haematemesis; IV PPIs may be used post-endoscopy for non-variceal bleeding.
Teaching point: Haemodynamic stabilization with IV fluid resuscitation and blood cross-matching must precede diagnostic or therapeutic endoscopy in acute upper GI bleeding.
Question 3 of 3
What is the most likely cause of this patient's upper gastrointestinal bleed?
Peptic ulcer disease is the most common cause of acute upper GI bleeding, accounting for around 50% of cases, and is strongly associated with regular unbuffered NSAID use (ibuprofen). Oesophageal varices (option C) are linked to severe portal hypertension and liver cirrhosis, for which there are no signs here. Mallory-Weiss tears (option B) typically present after repetitive severe vomiting or retching preceding haematemesis. Gastric adenocarcinoma (option D) usually causes chronic occult bleeding, weight loss, and early satiety rather than sudden acute mass bleeding, though it can occasionally present this way.
Teaching point: Peptic ulcer disease exacerbated by NSAID use is the most common aetiology for severe acute upper gastrointestinal bleeding.
Key learning points
- Haemodynamic instability (shock) in acute upper GI bleeding requires immediate fluid and blood resuscitation prior to endoscopic intervention.
- An elevated urea-to-creatinine ratio is a characteristic lab finding resulting from the breakdown and absorption of blood proteins in the upper GI tract.
- NSAIDs are a primary risk factor for peptic ulcer disease, the leading cause of upper GI bleeding.
This is one of 158 free cases
AskPreceptor is a study tool for medical students: answer first, then see the reasoning — including why each wrong option is wrong. Free, no sign-up required.