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Ddx
- PUD (DU/GU)
- Gastritis
- Oesophagitis
- GORD
- Pancreatitis
- Cholecystitis
- Gastric neoplasia
- ACS
- AAA
HPC
- Would you mind to describe what do you mean by having
indigestion/dyspepsia?
- Onset?
- Have you had this before?
- Epigastric pain ask SRTCOPDSARA
- Aggravating factors: food (GU), occurs in early morning (DU)
- Relieving factors: Food, milk (DU), relieved by antacids (GU)
- Associated symptoms:
Nausea
Vomiting
Haematemesis? coffee ground vomiting?
Anorexia (any loss of appetite?)
Early satiety (do you feel full after eating a small amount of food?)
Weight loss
Difficulty in swallowing? (dysphagia)
Any pain on swallowing? (odynophagia)
Heartburn
Bitter taste in mouth
Bloatedness
Change in bowel movement?
Blood in your back passage? (malaena)
SOB (anaemia)
fatigue (anaemia)
RF
- Hx of PUD
- Hx of H.pylori infection/bacterial infection in the stomach?
- Smoking
- Alcohol
- Medications especially NSAIDs, aspirin, AC, steroids, alendronate?
- Stresses
- Medical problem related to high gastric acid secretion in the stomach?
(Zollinger-Ellison syndrome)
Physical exam
- Epigastric tenderness
- Epigastric masses
- Supraclavicular nodes (virchows nodes-gastric adenocarcinoma)
- Guarding, rigidity, rebound tenderness (perforated PUD)
Investigations
1. Bloods FBC, U&E,CRP,ESR,LFT,Amylase, troponin(rule out other
causes), coag profile, group and x-match 2-4units , fasting
serum gastrin if recurrent PUD with negative CLOtest and no
hx of NSAIDs
6. Urea breath test (13C breath test) high sensitivity, specificity and
noninvasive but expensive.
Management
(depends on age (>55yo), ALARMS symptoms, severity of presentation ie emergency
with perforated PUD)
1. Conservative
- Reducing RF by discontinue NSAIDs or other medications, avoid
alcohol, stop smoking.
- Antacids magnesium trisillicate 10ml TDS PO
4. Bleeding-
- Assess and maintain ABC, vitals, hx and exam
- calculate Blatchford score (0 discharge and consider opd
endoscopy, =/> 1 admit and do inpatient endoscopy)
- 2 large bore iv cannulae, bloods (fbc,u&e.lft,coag,grp and xmatch)
- iv normal saline
- consider blood transfusion if Hb <7g/dL or CAD
- NPO
- Stop NSAIDs
- IV omeprazole initial bolus 80mg f/by continuous infusion at rate
of 8mg/hr for 72 hours
- Endoscopy
- If active bleeding, consider endoscopy therapy with adrenaline
injection/thermo-coagulation/haemoclipping/haemostatic spray .
- Surgical intervention :
DU- Duodenotomy and over sewing of the artery
GU- biosy and oversewing of artery or wedge resection of
ulcer if patient is unstable
- antrectomy and vagotomy if patient is stable
Shock
No Shock 0
Heart Rate < 100
Systolic Blood Pressure 100
Tachycardia 1
Heart Rate 100
Systolic Blood Pressure 100
Hypotension 2
Systolic Blood Pressure < 100
Co-morbidity
No Major Co-morbidity 0
Ischaemic Heart Disease 2
Cardiac Failure
Renal Failure 3
Liver Failure
Disseminated Malignancy
Endoscopic Diagnosis
Mallory Weiss Tear 0
No Lesion identified
No stigmata of recent
hemorrhage
All other diagnosis 1
Upper GI Tract Malignancy 2
5. Perforated PUD
- ABC
- 2 large bore IV cannulae
- IV normal saline
- IV analgesia
- NG tube
- Surgical repair of perforation + oversewn of ulcer and secured
with a plug of omentum.
**NOTES
1. Complications of PUD bleeding, perforation, gastric outlet obs