Questions for Discussion:
- What would be your initial management of this patient at this point?
- What are clues from the history and physical examination that suggest the location of the gastrointestinal bleeding?
A nasogastric tube is placed and the return reveals clear fluid.
The initial laboratory evaluation is as follows: Hgb-9.1 gm/dl, Hct-28%, WBC-13, 500 (normal differential) Platelets- 450,000, PT/INR/PTT-normal, BUN/Creatinine-45/1.7 mg/dl.
- What is a reasonable differential diagnosis for this patient? Give reasons for your differential diagnosis and defend the most likely diagnosis.
- What diagnostic tests would you perform on this patient?
An upper GI endoscopy (EGD) is performed and revealed a 1.5 cm duodenal ulcer on the bulb with fresh clot adherent to the ulcer base and some oozing of blood from the edges of the clot.
- What is the significance of the nasogastric tube aspirate?
- How would you interpret the endoscopic findings?
- How would you manage this patient at this time?
- What additional aspects of this patient's health must be addressed before discharge?