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Yeah, he stopped by assessing the airways. Make sure the patient speaking back to you in full sentences. Then you want assess the breathing because this patient is to keep Nick on. D is also hemodynamically unstable as his heart rate is 120 it's BP is from falling towards the lower end of normal. You want to administer oxygen, so administer maximum oxygen, which is 15, uses 100% oxygen for a non rebreathe mask. This is important because with Hemodynamic compromise, the patient is going to be slightly hypo perfused. So know enough oxygen going to the important organs and therefore it's important to and give him his much oxygen. It's you come do full respect your examination on order an erect chest X ray. This is important because this patient has presented with what could sound like upper gi bleeding, and you want to make sure that there isn't a perforation involved in this then, because he's unstable, you want to perform an ABG Next, you move on to your circulation so quickly and sure you have IV access, so this will be through two large bore Cannula City. They're usually gray in the UK um, or 60 engaged. So try and place one in each antecubital fossa when you placed on Canada's gets and bloods to get your standards for blood count, use need your LFTs. Make sure you get crossing on a cross match, which is important for urgent and urgent crossmatching off his blood type. If it's a women of childbearing age, get a pregnancy test the beach, the HCG I make sure you get elected, which will also get on your ABG. Now, this station is hemodynamically unstable because his tachycardic and he has given you a vague history off some sort of upper gi I bleeding with the vomiting off this coffee ground material. So you want to resuscitate him with fluids. So price this You want to make sure that it doesn't happen History of severe cardiac to see renal disease, but your son results station will be 500 mL off 5000.9% normal saline. Then you move on to do a full cardiovascular examination. I'm please ask for an e c G as his patients tachycardia. You want to make sure that you met measure his fluid output strictly for this, especially in elderly mom might be useful to insert a catheter. Now this patient has mentioned has said that he has vomited some coffee ground material and it is likely that this is Upper GI. I bleed. You see, my dynamically unstable on do. At this point, you want to assess whether you need to activate the major hemorrhage protocol. So the major hemorrhage protocol is establishing every UK hospital is a pathway that allows you easy access to blood products and then also seen your support. Um, usually at UK hostels, it's thestreet Andor did. 2222 number. You call a new state major hemorrhage and you give your location. So major blood loss may manifest as human Amick instability, which is a pulse over 110 breast spray over 30 which means the patient is probably hypo Perfused, so they have a lack of oxygen going to that organs. There's a store like BP might be low on if they have a low urine output that could also indicate a major blood loss. It's really important that you call for seniors support of this point. Do what you received when you, when you trigger the major hemorrhage. Protocol is immediate. 40 negative or positive Inman Red blood cells and four units off FFT. So you want to go on to continue your a B C D e s Testim in. So make sure you assess his his disability status is is GCS 15 getting B m's and jackets pupils and then look for any other causes off bleeding or any other reasons why he had seen my dynamically unstable because it might not be an upper gi. I bleed every time you perform in interventions of time, you give fluids. You want to get back to the start and reassess your a b C d. So you have successfully resuscitated him with to bolus is off normal saline on Did the red blood cells came very quickly on He was transfused three whole units off blood cells. After this is BP stabilized on his heart rate decreased to 80 eight's. You successfully resuscitated this man. Your former bloods come back, which shows a human globin or 5.4 bear in mind that these were taking before you transfused your bloods and it was a showed a macrocytosis with predominantly ridiculous sites. It was a showed a high urea off 17.4 with a normal craftsman's you happy that his renal function is preserved, his urea is probably high due to an upper GI. I bleed, and this is because blood in their stomach is the tabularized into your ear and the schools an acute increase in euros. That's an indication towards this being an upper GI. I bleed, his liver function tests and normal, including GGT. This is also important to look for the causes of his upper GI Bleed, which might be liver. It's Flushing was no more on his EKG. Just showed a Sinus tachycardia on interrupt. Chest X ray showed no signs or fluid overload or perforation. So now that he's human dynamically stable, you can start doing a bit more of a historical assessment. The first thing you should ask is the classic surgical history, which are the new Monica's sample allergies medications, past medical surgical history, last meal on events leading to his admission. So this is a really easy rule of thumb for surgical assessment in the cute setting, and it gets you're the important information for preparing a patient for better. If you're happy that this patient is stable, you can go on and take it more often in depth history. So this patient presents that what we think is an upper GI bleeds important thing is to go a bit more into detail on the description off the vomiting. So it was it fresh blood was vomiting prior to bleeding. He describes it as coffee ground, and you need a bit more of an explanation here. What color was it? What value was, and it could be really difficult to quantify the amount of blood loss in an appetite. I believe it is important to try now vomiting prior to her. Upper GI bleeding is important to establish as if they have been retching for other other reasons or vomiting profusely and then consequently having a bout of hematemesis. This might mean that they have a tear in there gastric lining, also called a Mallory Weiss tear. Then you want to ask about Melena. A lot of people are really familiar with what million it is. So it's important. Describe that this is a black Atari, often fell smelling stores vehicle sticky. And how long has this been going on for Have have they had any prior episodes off either Hematemesis or Melena. Then you want to take a full pain history, which includes Socrates, So establish whether they've had any epigastric pain or any liver pain in particular. Um, whether this pain is associated with eating or whether it's relieved by, for example, antacids. Then you want to establish whether it's radiating is it radiating to the back, for example, indicating maybe a night aortic dissection or pancreatitis on what time of day is? The pain were him up at night, which is quite a sinister type of pain. And how long has it been going on for, um, establish whether they've had any previous heartburn or dyspepsia? And so again, this could be quite difficult to explain. But it's really important to get history off. Heartburns haven't noticed any pain in the chest that I think it's related to eating. Have they had any reflux? Have they noticed any acid in there, the back of their throat? Then ask him about systemic features have their know sitting weight loss, night sweats? And how long has this been going on for? And then finally asking about dystasia have the nurse the difficulty swallowing over a prolonged amount of time. And is it getting worse? Anyone ask about their past medical history? So have they got a history off last record? You? Judy? No. Ulcer is a shit. Have they have got a history of gastritis or any other sort of dyspepsia symptoms? Do they have a past history off liver disease or malignancy and, in particular, gastric malignancy? Have they had any prior abdominal surgery on? Do they have any renal or cardiovascular disease, which is important to prepare the patient for theater? If you if you know they have really kind of acid, is is this will change management options You have asking about medications there are they taking any pain relief and, in particular ibuprofen, an approximate or any other type of non steroidal anti inflammatory drugs? Are you taking aspirin, which is a very common medication for healthfully? Patients take these. Both increased. Your risk of peptic ulcer is a shin, asked uh, steroids us about under coagulation. As the patient is like having you bid. It's important to know whether I had regulated and what this is for. As is not always indicated to stop and regulation. It depends on the indication for it and the amount of patients bleeding us about this phosphinates. So this phosphinates increase the risk off soft ajeel strictures and stuff for justice us and read that taken anything for any abdominal pain or gastritis, for example, Gaviscon antacid. It's for PPI. It's like lands up salt or a Meprosole. And, uh, this patient is hemodynamically unstable. You on establish whether they're on any anti hypertensive that you might want to hold for the time being until the patient is and well enough to take them, ask them about their alcohol intake. This is really important because it's a huge risk factor for both and gastric ulceration on liver disease. So ask them how much they drink a week. What they drink, how long they've been drinking for a minute had any previous history off high alcohol consumption. You know, I was asking about smoking as both alcohol and smoking combined. A highly increase the risk off the sofa justice, gastritis and malignancy and then you want establish their performance status so you can use the W H O performance status measure. You ask them whether they are independent at home, how long, how far they're able to walk without needing a rest on whether they've had any previous lunch operations that I've made them unfit. So our patient says that he's in passing black tarry stores for five days. He has had longstanding indigestion, which has been managed quite successfully with Gaviscon. Up until now, his stores are normal. Price is Molina with intermittent constipation. You had the history of a T I A. For which he takes daily aspirin and he drinks about seven units of alcohol per week. So now you want to move on to your examination after you've got your full history. So we're moving on to a first question. So we've got a photo here, often abdomen with quite distended related pains. So the question is, what is this? It's lunch ectasia spider me by but Medusa or Ascites. So I'll give you some time to aren't this question and we'll get back to the answer shortly. So for your examination, you want to start with your observation off the patient. Most importantly, here, you want to check with their have any stigmata of chronic liver disease. This includes quite a lot of different signs. Most commonly patient get patients get jaundiced. Have a look at their hands and look for any clubbing. Palmer erythema spied on you by Look for Duke Transconjunctival, look for gynecomastia, which is a sign in men of liver disease. Crease body hit her is another sign in both man it men and women. So for distinctly atrophy kaput. Medusa associate is so fluid in the abdomen. Any splenomegaly on her part? Um, ugly on any asterixis you want. Ask patients to put their hands out in front of them and see if they have a liver flat. You want to assess the patients patient for any signs of anemia? So do they have control time? Will Palo only angulus dermatitis on, then check for evidence of any careful apathy. So this is basically decompensated liver disease on it involves slowed mentation. So if the patient bit disorientated, I'm not quite with it on. Do they have a liver flat? Which is another term for asterixes to make sure you check their their hands and outstretched. You want to go on and do a full abdominal examination. So check for any epigastric tenderness or any masses in particular epigastric masses, which could indicate a gastric tumor checkpost, a pastor Megaly, which could indicate portal hypertension, which increases the risk over suffered your virus is check for ascites, which is another sign off. Liver disease on checked for pollution is, um, so has the patient. Is there an indication of perforation? And then you always want to do additional rectal examination to assess for Melena or any allergy are beating as well. So coming back to our question. So everyone's on Zocor but Medusa, which is completely correct. So this is a sign off liver disease, and it's due to portal hypertension and the veins around your abdomen get severely distended. Say, now you want to assess this patient with an upper GI. I bleed for his risk. So the first thing you want to do is distinguish between variceal and a non variceal bleeds. So for your virus, feel assessment. This is a clinical assessment on assesses. The likelihood off Varis is by establishing previous Paris's or any risk factors for liver disease or portal hypertension. So does he have a previous diagnosis of cirrhosis? Does he have any peripheral stigmata off your neck? Liver disease that you mentioned on our don't do? His bloods indicate liver disease that they have any previous radiology when it come radiology that shows cirrhosis or any other liver disease. So once you're established with, there's a risk off Paris is you want to go on to do the glass for black glass, go back to school. So this is essentially a risk assessment tool, which means that you can. If the patient has a low score, they are likely to be safe to be discharged on mansion outpatient setting. And if they have a high school, they don't even endoscopy within 20 hours in the glass. Go back for score. Includes quit simple measures. It's quite easy and quick risk assessment Tool to use includes blood urea, which, as you mentioned, indicates an upper GI bleeds chemo globin, systolic BP and then a few other markets, such as heart rates. Whether there's any presence of Melena, whether have syncope previous a plastic sees on previous cardiac failure. So back to our patients were association said successfully on Now we examine him fully. He's had epigastric tenderness, but no signs or perish in is, um, or abdominal mass. He's had no stigmata off chronic liver disease on a rectal examination revealed in a large prostate. On there was freshmen Lena on the glove, but there was no fresh rectal bleeding. So no bright red blood his last year. But for school is three, which gives him a predictable tallit e off. 11% indicates urgent endoscopy for this man. So until the next question me activation for you so you can answer, I wish may. Okay, The next question is the most common cause off Upper GI bleeding. It's peptic. Ulcer is a shin. Suffered your virus is a soft a giant cysts or Mallory Weiss tear. So we'll carry on and we'll let you answer this on. We'll get back to the answer shortly. Okay, so what are the difference was for an upper GI I bleed. Peptic ulcer. A shin that's offered your virus is bleeding gastric tumors. Mallory Weiss has a sulfur, Joseph's and bath limb off malformations. All the most common cause of opportunity bleeds. The most common cause in the UK is peptic ulcer disease, so this is about 26%. So about quarter of patients and presenting the upper GI bleeds haven't due to peptic ulcer is that are bleeding and then we have gastric erosions or suffer deal erosions, causing 16% a suffer. Joseph scores to 17% on Barris is causes 8%. So know a huge amount of a huge amount. Patients present with Paris is but a very important differential to exclude so peptic ulcer A shin is the correct answer. About quarter of patients present with peptic ulcer disease the upper job lead. So what is your management off on a project least we've gone through the initial results staged them for ongoing management. You want to refer, especially our patient who presents with a higher class go back for school. You want to refer them for an urgent and dusk piece. This is endoscopy within 24 hours. So as an f Y one, you want to prepare this patient for endoscopy. Here, you won't be performing yourself that you want to make sure they're fit to go, so make sure you correct any crossing. I'm a multi very important to get a full clotting profile, and this you won't be expected juice by yourself. But it's important to know what you can give to a patient with clotting abnormalities. Then you want to stop any offending medications. So we mentioned some of the medications that increase your risk off up a geo bleeds and that includes and said's aspirin on steroids. So make sure you stop these drugs and not worse in the upper GI bleeding you want assess that and regulation. So do you. Do the seniors want to continue and strangulating the patient blast they're undergoing there and oscopy? Or do you want to hold the anti calculation and then stopping the antihypertensive? If the patient is hemodynamically compromised for endoscopy, you want to make sure the patient has fasted for a least three hours. The patient needs to be consented on you to have a cannula in situ and a ballad group and save a swell and then make sure their patient has their case notes and all the observation shots ready to go down to the endoscopy in it. So how is the patient managed in and oscopy? So we split the management into number seal on virus. Your upper GI bleeds for no Marshall, a pretty Ablett, which mainly is peptic ulcer bleed. It's becoming melary voice has on a sofa justice. We usually use adrenaline injections. In addition, to another method that could be a mechanical, for example, clips, which is commonly used. It could be thermal crackle, a shin, which usually it's diet for me. Or he must spray, which is a topical, mechanical hemostatic agent, as well as, um, initiating and a calculating factors at the site of bleeding for variceal bleeds, every first line treatment is band ligation off the esophageal viruses on for gastric viruses usually is managed with from been injections sclerotherapy, sometimes also used. And if this is unsuccessful, we might, in such a sense taking Blakemore tube, which is essentially a balloon that's blown up and compresses the site of bleeding to stop bleeding. For variceal, bleeds patients that high risk off infection. So you want to give them prophylactic antibiotics. And if the above measures haven't worked and the patient goes on to have assessment for it tips, which is the trans drug, you're intrahepatic portosystemic shunt on. This is essentially a shunt that is placed in between the portal vein and the hepatic vein, which allows fresh bloods to go through the and it could bypass the cirrhotic liver on their four lessening. Their pressure on the Barris is so after the patient has undergone endoscopy. Had this it's assessment for the for the cause of bleeding and then the management. You want to do the rock all school. So this assesses the patients risk of re bleeding as well as the mortality risk for patient after endoscopy. So the Rachael score takes into account the patient's age, whether they had any signs of shock. So if their blood pressure's been low or they've had a heart rate had a tachycardia have do they have any comorbidities in particular cardiac disease or renal disease? And what is the diagnosis of the bleed? So, um, I'll revise tear has quite a low mortality risk, whereas malignancy has high mortality risk. I'm on. But what is Thea Biopsy results is well on the school school off less than three is gives you a metallic three of 1% whereas the school over six gives you a metallic trait or 15% quite a big difference. So a patient underwent urgent Dostie on a bleeding. Judy Know also was identified. This was successfully managed with the gel injections on diathermy after endoscopy, he was prescribed HPI Laurie eradication therapy. We're going to talk about about and the causes of peptic ulcers and each pylori. So on to the next question. So next question is, what's the most common cause of peptic ulcer? A shin? Is it smoking alcohol and sets? Or H. Pylori to will come back to the answer and bits. So let's just quickly go through the and asked me off the stomach. So the stomach is starts at the end of the esophagus, and it's comprised the cardia. The fund ists the body on the pyloric, Um, then under the body, you have the great curvature and then the last culture between the cardio and they're true. It's supplied by the left Kastigar tree and right gastric artery superior E on, then the left gastro epi prick artery on the right Gastric gastric report card tree imperially. We're going to briefly touched on the physiology. Just Teo. Improve your understanding off peptic ulcer disease. So we're going through it quite simply because that's quite a lot of complicated facility covered with the stomach. But essentially, the stomach is lined by a kilometer. Epithelial cells on these cells secrete protected mucous that protects the epithelial layer from the acidic stomach environment. The parietal cells secrete hydrocort acid by a proton pumps, and this hydrochloric acid is important. Teo digest the abdominal contents and also, um, activates other cells. Such a step. Synergen Gastrium, which is produced by GI cells in the antrum on this, also stimulates acid secretion. Where is somatostatin, which is produced by decell, suppresses acid secretions. It's important to remember which, UM, cells secrete gastrin, on which secretes my statin of what affect these. Have prostaglandins and peptides produce protective bicarbonate, and this bicarbonate is really important to try and temp down the acid in the stomach so that the the mucosal lining isn't damaged. So H. Pylori is a bacteria, a gram negative spiral flatulate, a bacteria that exists in about 50% of people over the age of 50 in the UK, has a much higher prevalence in know developed countries. About 90% on. It's usually the cause of Judea ulcers on about 70% in gastric pulses so that the Fletcher Flagellar on the H. Pylori bacteria allows it burrow into the mucosa off the stomach Lining on this means that it can go below the knees of acidic layer off the stomach and then live under Lee underneath the mucosa. And the way that HPV Laurie causes peptic ulcer and information is because it produced is your areas and your E is reduces ammonia from the urea that's already present in the stomach contents. And this raises thie pH of the stomach because ammonia is more basic than and then the acidic contents. So with this raised pH, the stomach lining is inflamed, especially in the antrum, so this actual inflammation causes depression off the D cells that we mentioned previously on This means that lessum are statin is is produced. Simvastatin inhibits acid production, so if there's less much statin, we get more acid production on. This increases inflammation in the stomach on this inflammation eventually leads to also information now in a touch on white and said's cause gastric ulcers. So this is mark ends of the most commonly cause gastric rather than Judy. No ulcers. Um, Andi. The reason for for this is because entered inhibit cox enzymes on Cox. The Coxsackie enzyme produces prostaglandins and prostaglandins is what helps produce bicarbonate, which reduces the pH on bridges. It'd the risk of information. So when we inhibit the Cox enzyme. We get a more acidic environment in the stomach and and therefore that causes inflammation of the gastric mucosa. So the most common cause of peptic ulcer a shin is as Ms you rightly, said H. Pylori. And this causes that 90% of Judea ulcers have mentioned, and 70% off Castro goals is So what other clinical features off peptic ulcer disease so patients often present with current abdominal pain. This is the most common presentation is usually happy gastric on, but it's often related to meals. So for gastric ulcers, they often present with pain shortly after meals worse and Judy losses. It's usually 2 to 3 hours after meals. You might might have heard patients say that they they present with pain when they're hungry. That, actually it's It's due to be the emptying of the stomach contents to about 23 hours after the beaten they might present with dyspepsia. So get any history of heartburn or any gastroesophageal reflux, and then get a history of bloating or belching, or whether they're felt excessively gassy, and then also for Hematemesis or Melena on symptoms of anemia. So ask if they have experienced any dizziness of their experience on get headaches or tachycardia or palpitations. Right? So you run tow next. Um, final question in a patient with dyspepsia, which of the following is not regarded as an alarm feature will talk about what alarm features. Ah, I'm surely is that weight loss dysphagia No response to pee pee? I've I'm deficiency anemia. A previous gastric houses. So alarm symptoms are any features alongside dyspepsia that are course concern on did indicate need for urgent investigation. So essentially patients with mom symptoms have features of dyspepsia in addition to one of the following bleeding or deficiency anemia, unexplained weight loss, progressive dysplasia, recurrent vomiting, prayers, tactic else is a family history off the gastro intestinal cancer or if they're 55 years older. So these patients need to urgent investigation with endoscopy on particular for medication or elimination off any gastric ounces. So you've had a patient presented with signs off gastric closes. Maybe it might be a gastric pain, and if they're presenting with alarm symptoms as mentioned, they need to go for another gyn and oscopy. Otherwise, they will undergo HPI. Laurie Testing of this is the most common cause, so this is commonly a carbon 13 urea breath test or a stool antigen test. HPI lower is managed quite simply. Sometimes it's managed to that investigation with a trial off HBO or eradication on This includes a seven day course of a PPI so lansoprazole or Meprosole in addition to two antibiotics, this is either amoxicillin on it, the Claritin license or METRONIDAZOLE and penicillin allergic patients. It will be clarithromycin and metronidazole. So this patients are given a seven day trial off HPI your education and and if their symptoms haven't improved by them, they're referred for an endoscopy. So in a patient with dyspepsia, which of the following is not regarded as an alarm feature? The correct answer is no response to pee Pee I. So weight loss dysphasia on deficiency anemia and previous gastric ulcers are all cause for concern, and the patient needs investigations for their dyspepsia. No response. VP eyes is not an alarm feature and does not indicate urgent investigations. So that completes our lecture on peptic ulcer disease on Upper gi. I bleeds, and I hope that was informative. 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