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Hi, everyone. Can you guys hear me? If you type a message in the chart, you can hear me. Hello, if you guys can need me because someone just put a message in the chat, please. Ok. So we got a reply from me. So I'm assuming you guys can hear me. So I think we're just gonna get started. Um So I'd like to welcome you all back to the Conquering Re Residency Teaching Series. Today we're gonna be talking about managing an upper gi bleed. So I thought it'd be good to start by kind of going through a case present uh case presentation if that will help. So on mus if you guys didn't know already, uh if anyone got any questions throughout, just feel free to put something in the chart and then I'll, I'll, I'll keep an eye on it for it and uh I'll be able to help you if I can. Ok. So today we're gonna be talking about managing an upper gi bleed. Uh It's obviously it's quite important er, when dealing with acute emergencies as they can deteriorate quite quickly in patients who are unwell, unwell very quickly. So, like I said, we think we'll start by going through a bit of a case based presentation. Er, so if you guys have any, uh, can you put your answers or ask the questions in the chart and we can go from there. So, uh today we have to talk about a 72 year old female who presents with black stools and some associated vomiting. If this patient was presented to you in A&E what questions would you guys like to ask? Does run a bit easier? Um and a bit quicker. Uh If anyone, if, if it's more attractive and everyone gets involved, we'll just be able to move through a bit a bit easier. So good. We've got, when did this start? If that makes it better or worse? We've got as well for Amelia. Thanks and any pain. So essentially, uh we'll start by asking our Socrates kind of questions. So we go through site onset character. Uh I guess the main ones uh for this presentation would be the onset. Was it sudden, was it gradual again? Is there any abdomen pain? Where is it exactly? Is it spreading anywhere at all? How to describe the pain? How many episodes of the black stools? How many episodes of the vomiting, any symptoms that associate with this or if you think in dark stools, uh cos we're talking about managing up upper G IB you might want to think about. So, blood loss, what kind of symptoms come along with blood loss. So the lightheadedness, fatigue, cold extremities, these are sort of questions that you want to ask about. And uh uh another one is asking about the vomit specifically. So the color of the vomit, it could be quite important in any blood. Notice, I think we can also ask about the number of episodes of that they vomited as well. Uh Another question. So another question to also ask is the patient on any antiplatelet anticoagulation. And given that we are cons querying the patient's bleeding. It's important to know, know this and we stop them as soon as we can just to prevent any further bleeding or any increase, er, further increased risk of more bleeding. So past medical history is also important, you want to ask about IBD, any gastric cancers, any bleeding disorders, this sort of stuff. Again, you can ask about a family history. It's anything that running in the family again, with the IBD gastric Cancers, for example, and the medications are very important. So, does anyone know why I've mentioned iron supplements or Vitamin B One of the side effects are, comes alongside taking these medications and why it is important to ask out uh constipation? I think you can sometimes get constipation. But the uh one of the side effects that I was looking for in particular is um dark stools. So you can actually get dark stools with iron supplements and sometimes with Vitamin B also. So it's important to keep that in mind. Um, again, you wanna look at the whole clinical picture of the patient, all the symptoms, all the past medical history, if it seems unlikely that the patient's bleeding and you can't find any cause, you might notice that they're on some iron supplements. And that could be a, uh, an, er, an answer for the dark stools, for example. And again, I've also mentioned nsaids and bisphosphonates. Um, if anyone, if anyone has any idea why I would, I would mention them specifically. So, um, both nsaids and bisphosphonates, if you didn't already know, can increase your risk of gi bleeding, it can uh cause damage to the mucosal lining and increase your risk of any, any internal bleeding, increase your risk of development ulcers. So, it's important to know, uh with both those medications that if they are none that can increase their risk and any history of alcohol abuse. So, as I mentioned with, with the vomiting, so patients that have high, high amounts of alcohol intake, uh can have bouts of quite aggressive vomiting that can cause tears in their esophagus. So when they have this tear in the esophagus, this can cause blood to leak down into the, into the stomach, get digested and as it's vomited back up, it might what cau it's what causes what you guys might know as coffee ground vomit. So, er, back to our case. So we've got a seven to see your female and we call her Miss Missus Jane do. She's presented with complaints of black tarry stools and hematemesis, which is uh blood in the vomit for the last 24 hours. So, um, the patient has mentioned that they've had 3 to 4 episodes of black stools as well as three episodes of coffee ground vomiting. There's no bright, bright blood, no bright red blood. Notice when she's wiping the bottom going to the toilet, I some epigastric pain, some dizziness as well as some generalized weakness. Not had any recent abdomen trauma, no fever or no significant weight loss. A past medical history includes peptic ulcer disease, type two diabetes, hypertension, af and osteoarthritis and the meds that she's on are warfarin, omeprazole, Metformin adca and naproxen. So, is there anything on this slide that you guys might have picked out that might help guide your diagnosis or is it is relevant to this presentation? So I know we spoke about uh medications a bit earlier. Has anyone, uh, give you a bit of a clue of the medications, any medications that we wanna be looking at? Cos it, oils mentioned the dizziness and weakness which uh could be cau er, caused by anemia. So it's, uh, it's important to know cos if the anemia's been caused by blood loss, uh, it can kind of point towards that, but in terms of uh, in the medications, anything in the medications that we should be looking out for that can either worsen our patient or be a cause for our presentation.