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Hi, everyone. I'm Natasha. We'll start in like three minutes time. We'll just wait for everyone to come and we'll start quite promptly. We will just give it another minute. Can everyone see the slide and can everyone hear me? Just pop a yes on the little chat box? Brilliant. Thank you. Ok, we'll just start. Um, hi, everyone. I'm Natasha. I'm currently in my f three year. Thank you very much for coming and joining us on this series. Um, you'll meet my colleague next week. So today is our second episode on this series and it's gonna be about upper G I bleeds. Um, very similarly, we're going to be talking about an A and presentation of upper G I bleeds and how you're going to recognize some of the common causes for this, how you'd investigate and manage an acute upper G I bleed in an A&E setting. We will also consider all of the etiology and how we're going to manage these clinical presentations appropriately. Just to let you know, um, if you're watching from your laptop, er, there will be a part later when we're doing case presentations where you have different clinical cases for you to download an app which is known as MD CALC. And, or if not, you can actually just use it on uh Google. It's just basically MD CALC and that'll just help us. It's one of the scoring tools that we'll use later. All right. So this is our gentleman that we are gonna meet today in A&E and very similarly as my previous session, what I tend to do is I want to just walk you through how you would meet a patient in A&E. So this is Rick Great. Right. That's all you know about him. Looks a little bit uncomfort looks like he's drinking something out of his fla looks a little bit shady, but that's not me being judgmental. But when someone comes from A&E, you basically see what they're coming with from the nursing triage. And what's your main headliner you could say? So this is a 65 year old male that's coming with vomiting. That's how much, you know, your nursing triage notes have said that he is vomiting. He is known to the department, he reeks of alcohol. So when he says he's known to the department, your healthcare assistants and your nurses know him by name. They know who he is. They get on because he comes in and out of the department for very similar problems and he doesn't look like he's actively withdrawing. He's a bit chaotic, but he's stable enough to be in the waiting room and the reason why this is so important is because if you've got someone that's obviously actively withdrawing or is being agitated or violent, you don't really want them to be sitting next to your 89 year old grandma Edna, for example, that's had a fall and a long guy and is looking terrified, but very similarly, you just want to make sure that the environment is safe. Um Just to make sure everybody can hear me, the slides are moving, uh just pop it down in the comments if something is wrong whatsoever. Um I've got my screen by my side. So that's the reason why I'm looking here, just looking at the chat Boxx. So so far, this is what you know, he's come in with vomiting and he leaks with alcohol and he doesn't look like he's withdrawing. So you try and talk to him and how you talk to him is basically you take this patient into what we call a day room. So these are just separate rooms where you see patients from the waiting room, you talk to them there and then you ask them to politely go and stay and wait inside the waiting room until we've got a definitive bed problem with the waiting room. When you take them, these patients to these day rooms is there's a little bed over there and Rick. Rick is getting very comfortable on that bed and he's not interested in talking to you at all. It is three in the morning. He is tired. He sees a bed. He doesn't want to listen to your questions. He tells you that. Yeah, I've been vomiting some blood. It's been going on for about three days now. But I think it's mostly my alcohol. I had some Jagermeister or some rum, I don't even remember, but I didn't drink yesterday because I wanted to go cold turkey. This is all, he's what he's telling you and what he tells you is that it's associated with a bit of dyspepsia. He's got this epigastric and he points to his chest. So, and he's that, I've got this really bad chest pain and I'm just so nauseous and because he came to our talk last week, you want to do a Socrates on him? He's not interested in uh like answering your questions. He's just telling you that everything is really painful. Everything hurts this pain that I'm having is neither here nor there. It feels sharp, it feels like pressure, it feels dull. He's a yes man. He feels weak and faint and yes, he might have fallen down while he was out yesterday. He even points at his head wound at the minute and points at you that he's had a rough couple of days and he just would like to use this bed and this opportunity to rest. So he's not really particularly being fond of your questioning or your idea that you need to examine him and you can't really remember much above from whatever we've actually managed to pick up. So you ask him a bit more, but you're getting a bit nowhere and he looks like he's about to kick off because he just looks a bit annoyed at you. He's a bit muddled and disorientated. He's yawning and sleepy and he's getting words mixed up. So you just do what you best can do is go through a bit of a systemic inquiry with this chat. So, guess what he says? Yes to almost everything under the sun. Unfortunately. So he says I've got chest pain. It hurts. Yeah. Center of my chest. Um, it's sharp. It's dull, it just hurts. I don't know what you want from me. Yes. I feel like my heart's racing. Yes, I feel short of breath. Yeah. I've been having a really bad cough. I've been bringing out this green, brownish type of, you know, productive sputum. Uh, no, I don't have pain when I take deep breaths in. That's silly. And I don't have any blood when I cough up. Yes. My bowels are darker but he thinks you're weird for asking him that and he tells you that he doesn't have any urinary symptoms, but he could go now. So, you'd like you to leave the room. He's got a headache and it's worse because he's talking to you. But he doesn't have any other neurological symptoms at the minute. So, everything else combined. Right. So, past medical history, he's a chap that's got COPD. He's a chap that's had previous mi he's got stents been placed in. He's got non alcoholic liver cirrhosis. He's hypertensive, but he's noncompliant with medications and follow up. So you look at his GP records and there's a lot of DNA S who do not attend, a lot of, did not attend and there are a lot of missed appointments and there's actually been no plan for all of the above actually any of this medical history. So for social history, you do ask him and he gets a little bit excited because yes, he can tell you about the different types of alcohol that he likes. So he drinks a bottle of rum and three cans of cider maybe about every two days. That's how much he drinks. He's about a smoker about 20 a day and sometimes he uses some cannabis and cocaine, but he promises you not anymore and he doesn't know what medications he takes. He has some, he takes it when he can if he remembers and he's not allergic to anything. So you look on the GP records and that's what hie stands for and you see that he's prescribed clopidogrel, aspirin, statins, bisoprolol and some inhalers. So, I mean, it's not like I hit what the topic is gonna be today, but in this context, from those five medications are there medications that you are worried about? Yes. Ok. What medications are you worried about? Which one? Make it easier? We've got antiplatelets over there. Yes. We've got our clopidogrel and we've got our aspirin. Beautiful. Yes. Like blood thinners. They are anti platelets and they're not going to help in the context of what this presentation is going to be about. So, any other medications just in general that would precipitate an upper G I bleed that, you know of that you'd be worried about. So any other examples? So we've covered obviously aspirin clopidogrel. But now just in the comment box, if you can tell me different types of medications that you are concerned about if someone has come in for in the context of an upper G I bleed. So yeah. So like I said, blood thinners, Rivaroxaban nsaids. Yes. So yes, 100% do X you've got nsaids. Can anybody think of another one? And this is in, for example, well, it's a context for when you give people when the immune system is a bit too rubbish and you just want to give them a little boost or that we throw into literally any inflammatory type of process. We chuck this little Sprinkle. Yes, cuticle, yes, steroids, prednisoLONE is absolutely horrible. But yes. So also in combination, so Nsaids with Ssris or Nsaids with bis, bisphosphonates are also extremely dangerous to precipitate your upper G I bleeds. And another thing to consider sometimes it doesn't precipitate it, but it makes it difficult to tease out information is ferrous when a patient is taking ferrous, fumarate, ferrous sulfate iron, their stool is gonna be dark and tarry. So it's really difficult to actually pick out whether it's actually Melena. Ok. So that's just something to think about when you're taking your history from these patients. And for example, if you're thinking about upper gib at the back of your mind. So anyway, back to Rick. So let's do a physical examination on him as best we can get his observations and that is perfect. Now, I'm gonna ask you guys very quickly, how would you examine someone in an A&E setting? In an acute setting? It's literally very quick. It's the best way to examine someone and cover all bases. And I want you to tell me what that acronym is before we move on starts with an A yes, exactly an A to E assessment. That's all I want. It's basically the best way, the safest way to ensure that you're actually going through what you need to go through and what would, if there's a problem it would arise at that specific time. So airways patent equal air entry bilaterally. He's a bit wheezy. He's got a bit of crepitations on both sides of his lungs. His cap refill is great. His heart sounds are perfect. No edema. His gcs is 14 out of 15. You're scoring it for confusion at this point in time. Um He's got very tender epigastric and also central chest there's no guarding in his tummy. His pupils are equal and reactive and his BMS are nine. He's a bit, he's got a bit of a tremor. He's a bit shaky. He is asking you whether he can just nip out to go get a drink from the corner store. He's a bit tearful. So you do a bit of a silver trauma survey because of that head injury wound that you see over there and you do a neurological examination because that's also very important. You've got someone that you don't have the most perfect history, a head injury, a little bit confused. A lot of different factors in this setting. And that's why you want to make sure and his head had laceration, you're in A&E so you take a look at it and it actually looks really superficial. It needs a little bit of glue. It's not even that complicated. It's literally cleaning it up, putting a little bit of glue and folding the skin folds together and you do apr examination because this is in the context of an upper G I bleed. And you want to see whether this person actually has melena, so anal to preserve no hemorrhoids. There is some Melena there. So let's find out also, please, I know I didn't go through it but ask your patient for, you know, consent beforehand, bring a chaperone with you and we'll go through all of that. But yes, um just for people that don't know. So what a Silver trauma survey is. It's here in the northeast and it's for patients that have come in with a fall and it's just like a very comprehensive primary and secondary survey that we tend to do. So what it is is basically going head, shoulder, spine, pelvic girdle, hips, knees and ankle, and it's basically ensuring that good range of movement, any obvious injuries, um palpating any bony sort of, any bony tenderness. So it's like a very quick musculoskeletal survey to ensure the main purpose is obviously to ensure that there's actually no signs of c spine tends. And there's no signs of, for example, the old ladies that fall and had a long line. You wanna ensure that they haven't gotten enough a neck of fema fracture. But that is essentially what a Silver trauma survey is. So I understand that we are supposed to be talking about upper G I bleeds. But I wanted to talk about a very realistic scenario that you see in A&E, right? So Rick has a lot of current issues. He's got a head injury with a GCS of 14 out of 15 for confusion. He's got this epigastric very central type chest pain, which he's saying everything yes to. He's got a history of an M I with stents and he's got this history of hematosis and Melena and he's got some productive sputum as well. So, what are you prioritizing and why give me a second, I'm just gonna ask you guys. Yes, I would like to just see what you would think about. Ok, great. Give you guys like, so let's a bit. Let's see how many people just give it a minute and then we'll take it from there. Uh We can do slightly better than that. We can get another 10, 10 people to definitely respond. It's just on poles. What would you prioritize in this history? We've got this unconvincing history of epigastric chest pain in a patient that's gotten an mi in the past with stents. We've got this person that has got this new head injury, walking around, confused. He's a very young chap. Is that concerning at all? And we've got this hematemesis and Melena for the context of upper G I bleed that you're also concerned about at the minute. And you've also got this productive sputum. But I can see that nobody's actually prioritizing that at this point in time. All right. Well, then thing. So can everybody see the slides again? I hope so. Yeah. So it's a bit of a trick question because a lot of these things are important and actually, you'll find out that when you face with some patient like this, there are a lot of different things that are equally just as important and it's not just about focusing entirely about one, but it's about going through A B and C and you'll find out what you'll get to. So in that logic, what you will find as well is that for example, chest pain, hematosis, Melena, you'd actually find that it would come up then through the ECG, if you're worried about changes, then you'd also find out if their BP was tanking or if they became tachycardic and you would take it from that. But again, I would agree with generally what everyone has said that, you know, epigastric, chest pain as well with the head injury and hematosis and melena. So let's discuss it is, is GC S concerning? Yes, we know that. What are your differentials for this GCS that is concerning? Why do you think his G CS has dropped a little bit? Any ideas, any differentials as to what you are thinking about? Let's have a look. Yes, absolutely. Perfect alcohol access or a subdural. Yup, confusion. Yup. Just trauma. Izzy becoming encephalopathic as well. No. Yep. Beautiful. His chest pain versus the epigastric pain. We've already talked about it. Are we thinking about, you know, an acute Coronary syndrome? Are we thinking about, you know, upper G I bleed at this point? Are we thinking about an acute abdomen? Are we thinking about aortic syndrome which will be covered next week, by the way? And what is the degree of anemia and hypervolemia? And this is something that I've talked about earlier, which is basically looking at his vital signs, which you will be doing. And as, as you're doing the, your A E you'll pick this up then. So it's looking at the signs when you're actually assessing him, listening for his heart sounds, listening to his heart rate, seeing whether he's tachycardic. Is he hypertensive? Does he look dry? Does he look shut down peripherally? And my favorite question so far, are there signs of chronic liver stigmata that might suggest liver cirrhosis? So I know a lot of people might not remember it or might do. It's been a while since I did. But are there any signs that you can see, you know, just on a general inspection from a person for liver stigmata? Like for example, a really common one? Well, pretty really in between one is clubbing. I don't wanna give out the main ones because I think you guys will know that. So something like clubbing. Anything else that you guys can think of accident? He just showed it. Los of Chester spider Neva liver flap. Yes. Um Beautiful. Yes. So let's have a look at this picture. So everybody will know it looking at Hepatomegaly cirrhosis. Obviously, I know you don't see that this was just to see the other things tip medusa. So you're seeing the dilated veins, gynecomastia like I said, just scleral icterus, palm, erythema spider Neva. Someone has already brilliantly said ecchymosis, leukonychia, clubbing and asterixis and uh fe or hepatic. Yeah, brilliant. So what are your next steps with this wonderful patient that you have at three in the morning who's got so many things going on, you've already done this, a physical examination with a chaperone. So the reason why I wanted to emphasize this right now is because sometimes these patients can tend to be well, a little bit off in the sense that they can just get really upset with you, agitated, violent, abusive at any point. Or they could honestly just deteriorate so it can go either way. So sometimes it's really good to just have a second pair of hands with you just in case getting a collateral history, extremely important because you're not really getting very much of it from him. Having a look like what we did for any stigmata of liver disease and doing apr examination really important. Don't try and pawn it off and don't try and say, oh he said that it looks dark so it must be no silver trauma surveys is just a quick way of doing a ATLS very primary secondary survey and relocate your patient. He's currently in the waiting room at the minute and just put him into a day room which doesn't have any eyes on him or observations. This is a patient that could go off. Like what I said earlier, he could just start getting really agitated, he could leave or he could start deteriorating and become really, really unwell. In either one of these scenarios. You'd really like someone to just actually have eyes on him, cannulate him and get some bloods off of him, do some baseline things like an ECG and a chest x-ray. And you'd consider a CT head because of this new confusion, this head injury, whether he was taking the clopidogrel and start him on si a protocol for alcohol withdrawals, keep him nil by mouth. Give him plenty of IVT and analgesia as well. And we'll talk about that for why. And finally, let's talk about scoring tools. So in the context, again, of upper G, I bleeds anybody know the scoring tools that we are gonna use. Albert. So has anybody ever heard of M MD Calc? So we tend to use this a lot here. Yes. Glasgow something is your Glascow blotch foot bleeding score known as your G BS. Exactly. Yes. So this is what the um app looks like. And if not, you can just search up on like a separate tab on your computer or something, just look up for MD Calc and pull this up. We are going to be doing a few cases very shortly where you're gonna need to actually enter in these um numbers and do this and then we can find out the result. So I'd advise you just do it now so that when we actually are at that point, we're saving time. Just be mindful though. For in future hemoglobin, it depends which trust you work in. So just be men be mindful that the unit does change from gram to liters. To deciliter and milli M to liters. But we'll keep it to these two at the minute. So what is this scoring tool? Actually? So nice guidance have actually said that this scoring tool is a risk assessment tool and it's a choice for EED and how it is it stratifies that. If you have a score of zero, it's meant to actually prove that you have early discharge without outpatient endoscopy. That is part of it. But what it does do most of the time and you'll find when you actually do calculate it is that it gives you an idea of whether they are medium risk or high risk of bleeding or for an upper G I bleed. There is a second scoring tool that we tend not to use. But if you work on gastro or if you work on endoscopy, you will see it's known as the Rockel scoring and there is a pre endoscopy and a post endoscopy. And that is basically a predictor of mortality that you can see um a score of three for a rocker score before endoscopy can mean a 10% mortality rate and a score of six can mean a 50% mortality rate. The third scoring tool is known as Ames 65 which is again a predictor of mortality. We don't tend to use this, but it's always just good to know just in case someone decides to quiz you. So how does the Blackfoot score actually work. It is based off of these things, your urea and your hemoglobin, your BP, other markers like your pulse, melena syncope, hepatic disease, and cardiac failure. What I want you to just be aware of is why it jumps so high when you're using it is one, just a slight increase of your urea by one already gives you a score point of three. Whereas a slight drop in your hemoglobin just under 100 gives you a score of six. So someone with known iron deficiency anemia, for example, will already have a score of higher than six sometimes and that just increases the risk. I think your maximum score can be up to 23. So this is just basically what we were talking about earlier. Um Glasgow helps with the low risk to consider discharge, moderate, helps you understand whether you're knitting them for endoscopy and high risk helps with L to like determine mortality as well. Uh Yes. So let's go to the cases. All right. Just give me a second. Do this, stop presenting and we'll do this. OK. That kind of scared me for a second. Is a technical error. Can everybody see those? Can everybody see the slides for this? Beautiful. So this is what I want you to do, like I've mentioned earlier. Can you either download MD CALC or just put it up on your search browser? Because we're just gonna do like four cases right now and take a little break from Rick, a very chaotic patient. So what I want you to make sure is that you have put empty cal you looked for Glasgow blotch foot score and you ensure that your unit of measurement is for hemoglobin is gram per liter. And for bun which is your urea is minimal per liter. I'll give you guys just a minute. I really have faith that you guys will do this. Great. So we're living in an alternate reality as Rick would say, we've got Richie. Richie is a 26 year old guy and he's come in because he started vomiting coffee ground blood. He says he uses those words. Exactly. Cos as all 26 year olds know we all know what coffee ground is. He's saying that he's got diarrhea loose stool going about 20 times a day, just really loose. He went out over the weekend, had a bit of a bender because he was fresh as week for some reason and had really like his, he loves his takeaways from the weekend. He's got really crampy abdominal pain. Tummy's nice and soft. No real guarding his s are stable. He's got like a low grade temperature. He's fit and well, no regular meds. These are his blood. He's got a hemoglobin of 100 and 35 urea of five. A systolic BP of 100 and 12 and a heart rate. 65. He's got no signs of Melena on his pr he's got no he paic failure, no heart failure, no syncope. There you go. What do you think his Glasgow Blatchford score will be? I ignore this bottom bit right now. Just focus on Urea being five. I wish I had an option to like put some like pulling music on that would have been quite good. Like elevator music. You guys are doing very well. I mean, you, you're definitely on the right track. Yeah. Keep going, keep going. I believe I feel like there are more of you. You can definitely be doing this. All you need to be doing is just using the calculator and just entering these numbers and for associates symptoms like Melina his heart rate, heart failure, um hepatic failure, they all. No. OK. Let's try to get to 15 and then I'll move on. I won't pressure anyone. You just have to be mindful of the time as well. If that's all right. Any takers. All right. Yes, everyone majority was right. The answer is zero. His class go back. Physical is zero in the sense. So this is what it should look like on your screen. 135 512. He's male. No, no, no, no, no. It is zero low risk which patients do not require any medical intervention. Mm So what does this mean? All right. So first I want you to be thinking about his differentials. So now very quickly I would like to go back and I would like to change this case and say what if his Urea was seven? Would, would that change anything? One second? Um Oh, brilliant. Yes. Yeah. So everything is the same apart from his Urea, his Urea is now seven. Beautiful. Yes. Well done guys. His Glasgow bach would become a two. Does this really change things? No, you've got a young chap that's come to you with this unconvincing history of Melena. He's also mentioned a few things that should ring some alarm bells. He's had a takeaway. He's got diarrhea, he's got crampy abdominal pain, he's got a lower, you know, um sorry, he's got a low grade temperature. He's vomited a few times as well. His blood show his CRP is ever so slightly raised as well. So LTs are quite normal. Urea by the sounds of it as well. Looks normal. So your plan is consider your differentials. This does not sound like a convincing upper G I bleed. So for example, think about an acute abdomen, think about gastroenteritis, uti pyelonephritis. If Rick was a girl, I mean, if she was a girl, you would think about, is she pregnant? Are there any gyne symptoms? And if they were stable enough, you could try a surgical same day center while they're there or if it's during the day to just offload at the minute because it doesn't sound like a convincing upper G I bleed. Now, if his Gla Gaba score was two. The reason that it was two was because his urea was seven. Number one, you still discuss with your senior on A&E, but likely this would more likely sound like a case of gastroenteritis where he is just extremely dehydrated. That is what it sounds like. It, it doesn't sound like a convincing upper G I bleed history. So based on what you would do, you would actually just replenish him, rehydrate him. See how he feels later. You'd repeat his bloods if you want to repeat his gas, make sure everything's all right as well as venous blood gas. And you could actually just discharge him again. Trial of a PPI at home with safety net saying look if it doesn't get better in the next 24 hours, come back to A&E next. We have Ricardo. Ricardo is a 57 year old guy. Um, he's a businessman. He's been vomiting fresh bright red blood. He said that he just went on a bit of a retreat with his mates on the weekend. He's been out on a bit of Benders, lots of dry retching. There's no changes in his bowels. His abdomen is nice and soft. Sorry, everything's ok and his os are all stable. These are his numbers. What do you think it is? Oh, now it's close. 10 or 12. That's great. Just for bonus points. If anyone wants to actually drop down what they think? This sounds like. It's a very classical history for one of the differentials. Give it one more minute. I think I'm more of you. So you guys can definitely answer this. Keep going. Keep going. Yeah. Well done syndrome. Yes. It's perfect to. Also we'll be talking about differentials shortly. Esophageal varus is. Yes. So this is actually a classical history of something known as Mallory Wise tea. Beautiful, well done. Yes. But we'll talk about the differentials very easily. Um So what was, was it Miriam? Yes. So why does urea get raised? I don't really have a slide for it. But basically, when you've got an upper G I bleed, that actually happens, the blood is digested and becomes protein. This protein then gets taken to your liver via the portal vein and it gets metabolized into urea. It's just within the urea cycle and that's just why it gets picked up. So brilliant guys. His G BS score is 10. So we got it here. Now, someone with a G BS score of 10, you admit them. OK. They're high risk. As you can see over there, the G BS grade of zero suggests a high risk G I bleed. Now, the first question that you need to ask yourselves is, are they hemodynamically stable? So how do you check that? You obviously check the patient, you know, see that observations and the numbers on the screen. So see how your patient is symptomatically and how well they look, you don't want them to be peripherally shut down. You don't want them to look like they're dying to be honest with you. Obviously, number two observations, you don't want them to be extremely tachycardic. You don't want them to be extremely hypertensive with their BP is down in their boots. Um, don't want them to start deteriorating with you into shock and bloods on the screen. You don't want the HDP to be through, through your boots where they're actually bleeding, bleeding loads in that sense where they know the HB is 50 or 40 the is crazy. So this current patient is stable. So because he's stable and for example, this is 3 a.m. in the morning, you admit them to A&E you cannulate, you take some bloods off, you grip and save them and you transfuse them if needed. In this scenario, not needed. His HP was 72. He's stable, so it's fine. Start him on an IV PPI keep him nose by mouth, start him on some IVT. Now, our protocol here in A&E is that whenever we have a high G BS score, just literally anyone that we're admitting, we have to let the medical registrar aware. So you speak to the medical registrar, this patient will get moved up to your medical unit and they will speak to the Onco Endoscopist in the morning. Now, if this is during working hours, 9 to 5 and you have someone like this, you would just call the endoscopist and let them know and let them decide when they would fit this patient into the list. Hope that makes sense. It's now recur recer is one of my, was one of my favorite patients. So he's an 83 year old chap that's been found on the floor. His pen alarm finally went off. They came to get him and he had this coffee ground vomit stained all over him. All you know is from the paramedic notes that he saw a GP for his chest infection. Um He has achy joints. He uses lots of over the counter medications. Lot of boxes with beside him, he's got a past medical history of COPD hypertension, af ischemic heart disease, rheumatoid arthritis and he's on aortic valve replacement and you do APR on him, Melena. His HB is 68. His urea is raised. His systolic pressure is 87 and his heart rate is about 100 and 27. He's got Melena. And yes, in this instance, he's got syncope because he's just been fat on the floor unconscious. So we're gonna say yes to this. What's the difference between group and save and group and hold? Um So in our trust, we say group and save and group and cross match where a group and save is the first tube and the group and cross match is to actually determine the type of blood and the antigen with it. I'm not too sure. Otherwise, it depends on your trust as well. So, also now, while you're doing this, I want you to pick out and ask me a few questions from his history. I know there's not much, but just dabbled in a little bit there in his history right now. And we've talked about the medications that we are worried about. Do you think he's taking any of these that would precipitate an upper G I bleed and make it worse? NSA. Yes. Oh, wow. Yes. Exactly. No. Brilliant. Yes. He was prescribed steroids for his chest infection and yes, he was taking nsaids and the other one was basically, I was indicating towards this af and his aortic valve replacement. So you guys are getting it 100%. It's 16 majority is great. So you find out he's been treated for doxy and pred for, for example, noninfective exacerbation of his COPD. He's been taking paracetamol and Ibuprofen and codeine. He's on Warfarin for his af and aortic valve and he's been taking ferrous, but his last scope was about 10 years ago and he's non iron deficiency. So what do you do with this chapel? You know that he is not stable with you based on his vitals based on his science, based on his classical bach score. It's very convincing. Obviously, of upper G I bleed, you ate A E and you stabilize. Do you need the major hemorrhage protocol? You can set at that point, you can definitely put it in, get your IV access, get some bloods off of him. So group and save cross match, transfuse with red blood cells as needed for his warfarin. Obviously, you'll wait for his inr but likely it'll be prolonged and you'll definitely need to think about vitamin K. Be plex is if you're in a special situation, you need to think about it. You will not be making this decision by yourself. So don't worry about it and you can consider tranexamic acid in trauma. Now, something that we tend to negate and forget in these instances is speaking about escalation status and updating. So if the patient is actually quite conscious, is able to talk to you, update them about what's going on what the plan is, explain to their next of kin, but also explain how unwell they are at this minute and think about things like do not resuscitate order. Um It is always fine to have that discussion when you think it's needed, they might not be agreeable to it, amenable to it, but it makes the person that actually needs to put in this discussion later easier, also urgently make sure the medical registrars is aware of them and endoscopist on call because what you likely find is that unfortunately, recall is not your perfect candidate. And you might find a lot of gastroenterologists and just in general for any big procedure, he is not a suitable candidate to actually go for it because he might actually die on the table and that's something to consider. And now we get our chap, Rick. Let's come back to him. Ok? Cos we deserve to, we need to think about Rick. You guys already know the drill. So let's just do him. What I want you to think about is right now is the fact that you knew all of this history. So I'll just remind you he was vomiting, coughing ground. He has Melena. He's got this epigastric chest pain. His gcs is 14 and 15 and he's not actively bleeding with you. So there's no actual hematosis with you at the minute. His CT head came back completely normal. His ECG is normal with old ischemic changes from his previous MRI with stents HB has come back as 86. He is slightly raised. His systolic BB is holding up. His heart rate's a little bit on the borderline tachycardic. His troponin has come back as single digit. It's nine. We don't need to worry about this. He's got Melena and he's got hepatic disease. He's got non alcoholic liver cirrhosis. I don't think I'll be able to let you guys respond for too long if that's OK. We've just got a few things that we still need to talk about very quickly though, but I think you guys are absolutely getting it. Um His class bach score is 14 brilliant. So very similar, not as imminent as reco but R is obviously still a very high risk of a upper G I bleed. So you admit them, you think about whether they're stable, we've already done all of this. But basically the difference is that start him on some IV PPI start him on some antibiotics prophylactically, start him on a know by mouth IVT and let your medical registrar be aware of him. Now, if it's 4 a.m. in the morning and these are his vitals, you would likely just wait until nine in the morning and tell the on colonoscopist because he's stable and himself, they don't need to actually come up and actually do this right. Now. If he was unstable, you would call them immediately in the morning. Those were all the cases. I hope you guys enjoyed that. Now, I'm gonna go back to finishing the presentation. Ok? I hope everybody can see this screen right now and we'll just go through it. Epidemiology. Basically, upper G I bleeds extremely common in Ed. You'll see about 50 to 70,000 of them per year. This is from nice in the UK. Overall incidence of this would range from about 84 to 100 72 per 100,000. So it is still extremely common. It's extremely high incidence wise in the elderly and also lower socioeconomic groups. And despite changes in the medical management and how much we've actually progressed, mortality has still been about 10% for the last 50 years. So it's still extremely high mortality still extremely easy for them to deteriorate and become unwell with you. So what exactly is up A G I bleed? And how does it actually work? An upper G I hemorrhage is defined as a bleeding which occurs from a source proximal to the ligament of tris. So this is your ligament of tris. It is basically a suspensory ligament that hangs and helps you. So this is ac your ligament of the duodenum that marks the Denno duodenojejunal junction. So how this helps you is to understand that anything above this junction shows an upper G I bleed, anything below becomes a lower G I bleed. Clinical presentation. We've already covered this signs of anemia, hematemesis and melena most commonly and obviously to a more severe degree, you're thinking about shock, whether that's hypovolemic shock or septic shock, I can go into that as well. Does that all make sense? Risk factors? Again? We have been quite good and we've actually discussed quite a bit of that as well. We have talked about nsaids, anticoagulants like dox and warfarin alcohol abuse, alcohol excess, chronic liver disease, chronic disease, kidney disease, advancing age and previous peptic ulcer disease or h pylori infections. So now this is not, not trying to do a whistle stop talk, but we will try and focus and see how we get on. I'm just going to quickly try and explain these different types of etiology and we're gonna break it down into esophageal gastric and duodenal. OK. So let's talk about esophageal. So where we are, we're going to be talking about varices, esophagitis and malignancy varices. Sorry guys, varices, as you can see at the top is basically abnormal dilated veins that have been engorged and they are secondary towards the portal hypertension that have increased that pressure and cause them to dilate Burt and then rupture. What you'll find out is that because of the increase in pressure, it actually leads to the development of different collateral circulations. And that's why you can see things like your kapp medusa. So that is basically your superficial veins through your umbilicus. You can see things in your rectum causing your hemorrhoids, things like that. The second thing that we were talking about was esophagitis, which basically mimics GERD, it is dysphagia and odynophagia, painful swallowing. You've got these similar symptoms like heartburn feeling like you've got something stuck in your throat like globus, a hoarse voice and a dry cough and an endoscopy. You'll basically see this esophageal irritation. Malignancy is the same for all three criterias that we're going through. So you would obviously be worried of your bees symptoms like your weight loss, your night sweats, your reduced appetite and on OGD. When it's actually done, they might see a mass, they might see something that is obviously enlarged. It looks, you know, it doesn't look benign. They'll take it a biopsy and they'll take it to histopathology. No, let's talk about gastric So, in gastric, we're going to talk about peptic ulcers. That is everybody's favorite topic. So, peptic ulcers are basically two ways of thinking about it, your erosion and your ulcer itself. So, before your erosion, you're thinking about this break in the lining of the mucosa, it's a very superficial and a partial break. But that ulcer is a deep break towards your epithelium or your mucosal surface. And that's how you get your peptic ulcers. We've got gastric ulcers and duodenal ulcers. Uh something that I learned a long time ago, um, just by clinical symptoms is when pain is relieved or exacerbated by eating. So, pain is relieved by eating in duodenal ulcers and pain is worse when eating for gastric ulcers. So, very commonly, how you see peptic ulcers and things that can make it more common h pylori infections, your medications that we've all talked about and also you want to avoid triggers like spicy food, obesity, smoking, alcohol. And it's just very important to understand that first line eradication therapy is for seven days and how you do that is basically a course of PPIs. So, omeprazole and you want to make them long term a seven day course of either amoxicillin or if they're allergic clam mycin and metroNIDAZOLE gastritis. Very similar inflammation of the lining gastric cavity, uh very similar mimics GD as well. Um, can be caused by peptic ulcer disease or nsaids or alcohol and mallory wise tear is that linear like mucosal tear in the break of the mucosa. And you see this very common history of um typically episodes of these hematemesis with blood streak, vomit with multiple episodes of just retching typically happens after an alcohol binge and on OGD. Um Sometimes you'll just see a little bit of a lesion, but it resolves spontaneously by. Finally, we've got duodenal. So duodenal again, we've got peptic ulcers and we've also got inflammation of the duodenum. So very quickly, I'll let you guys just have a look at this. We don't have much, much longer to go. But for duodenal, very similar, we've already talked about peptic ulcers, which is great inflammation of the duodenal lining. The only other thing was obviously, it's known as an aorto duodenal fistular and that is a very self-limiting bleeding episode. It doesn't happen often. It's only for people that do have um a vascular graft for aortic aneurysm where they can present with retrosternal like abdominal back pain with signs of melena, an upper G I bleed of hematemesis. And this is why a fistula has happened. So this is just an incidence to just show what's the highest and 26% is peptic ulcer disease. The rest of them are well separated amongst themselves. But most common peptic ulcer after that gastritis like ger management, always a e patients, we've already covered this. So I'm not gonna cover this one more time, but you'll find out most of your problems will be in airway breathing and circulation and now very quickly management. The reason I'm not spending too much time on this is because you'll realize that you as junior doctor, you will not always be having to deal with this alone. You will have a specialist with you, but it's good to understand what exactly gets managed and how does it actually get managed. So let's talk about non varicel first. So non variceal bleeds, we're thinking about peptic ulcer diseases and it either gets managed by medically like what we talked about PPI S and also sometimes prophylactic antibiotics. But PPI long terms and that trialing to see how long it lasts for and whether that's improving endoscopically, there are two things. It's basically the idea of using adrenaline and another modality. So you can use mechanical clips in adrenaline or thermal coagulation with adrenaline and vari you'll actually find out like for example, what we were talking about the engorged veins, those are variceal bleeds, the medical Teli which is a pla K vasoconstrictor. And it's basically to reduce that portal pressure that is causing all of these problems and also prophylactic antibiotics to prevent spontaneous bacterial peritonitis. Endoscopically, you've got band ligation which is done very acutely, but it has to be repeated every 2 to 4 weeks to see until completion. If they continuously fail this, it might have to go for interventional radiology for embolization. And then we think about tips. This is no longer done anymore, but it's still mentioned. So it's a bit rare. But what tips is, is basically um a transjugular intrahepatic portosystemic shunt. And that's interventional radiology that basically causes a shunt to between your portal and your systemic venous circulation and reduces your portal pressure on your left there. You basically see this Seinen Blake more tube and it's known as a balloon tamponade. What I meant was that the tube actually isn't done as often. Tips is still done extremely often. Sorry for confusing the tube. But the tube is basically done as a balloon tampered out only for about 24 hours because any more longer than that can actually cause necrosis. Thank you very much. So, if you guys do not mind, you know, if you have any questions whatsoever, that would be great. And if you don't mind just completing the feedback form for us, I would extremely appreciate that. Do join us next week. I would really appreciate if um you guys joining us again, we are talking about aortic syndrome next week and you'll meet one of my colleagues. Doctor Harry. Anybody have any questions, I'll try to answer them. Thank you very much. Just you guys, please, please, please do our feedback forms. It really helps us to see. Yes, you can, you can go back on medal and you can actually just see the slides and watch the presentation again as many times as you want to. That'll be great, sorry for rushing the last few minutes. I think the cases just took a little bit longer, but um I was trying to do something different and just give you guys a bit of a chance to practice using the scoring tool. But yes, you can definitely get the slides. Oh, thank you guys. I'm really happy that you guys enjoyed this. Um I'm really hoping that this um series does. Well, we've got plenty of different things. Um So thank you very, very much. Please do complete the feedback form. Thank you again, you guys have a good day. Thank you very much for coming for this on a Thursday evening. I appreciate it very, very much.