Abdominal Pain, GIT BLEEDING MEDICINE

1. ABDOMINAL PAIN
AND GI BLEEDING
MOHANTA DEVIPRASAD 19-1194-875

2. ABDOMINAL PAIN
• There are various causes of abdominal pain including, but are
not limited to, indigestion after eating, gallstones and gallbladder
inflammation (cholecystitis), pregnancy, gas, inflammatory
bowel disease (ulcerative colitis and Crohn’s disease),
appendicitis, ulcers, gastritis, gastroesophageal reflux disease,
pancreatitis, gastroenteritis(viral or bacterial), parasite infection,
endometriosis, kidney stone (nephrolithiasis), abdominal muscle
injury, abdominal hernia, lactose intolerance, celiac disease, food
poisoning, menstrual cramp, peritonitis, serositis, ischemic
bowel disease, vasculitis, abdominal aneurysm, abdominal organ
injury from trauma and constipation.

3. CHIEF COMPLAIN
• “My stomach has been hurting for the past few weeks. Over the weekend, I noticed my
bowel movements were black and tarry.”

4. GENERAL DATA
• Name- William Smith
• Age- 62 years
• Sex- Male

5. HISTORY OF PRESENT ILLNESS
He presents to the emergency department on Sunday
evening complaining of intermittent burning epigastric
pain for more than 2 months. His pain is non-radiating
and occurs to the right of his epigastrium. This pain
changes in intensity and is worse with meals. He also has
noticed intermittent belching, being bloated, being weak
when walking, and complains of nausea after eating.
Since last Friday, he has been having black, tarry bowel
movements. He does not have any history of PUD or GI
bleeding and has not experienced anorexia or vomiting.

6. PAST MEDICAL HISTORY
• Chronic obstructive pulmonary disease (COPD) for
the last 10 years.
• Diabetes Mellitus for the last 10 years.
• Osteoarthritis for 15 years in the right shoulder.

7. FAMILY HISTORY
His father died at age 55 of an acute MI and his
mother died at age 66 from lung CA. He has three
siblings who are alive and well.

8. SOCIAL HISTORTY
• Presently employed as an accountant.
• He is married and has three daughters.
• He still smokes a cigar occasionally despite his COPD, and he drinks a case of beer per
week.

9. MEDICATION
• Metformin 500 mg po twice daily.(DM Type-2)
• Aspirin 325 mg po once daily. (NSAIDS)
• Ipratropium MDI 2 puffs 4 times daily Albuterol MDI 2
puffs PRN. (COPD)
• Ibuprofen 200 mg 2 tablets PRN shoulder
pain.(NSAIDS)
• Maalox 1 tablespoonful PRN stomach pain.(ANTACIDS)

10. ALLERGIES
• Penicillin—hives

11. ROS
Abdomen (+)
• intermittent burning right epigastric pain for more than 2 months
• intermittent belching, being bloated, being weak when walking
• nausea after eating
Rectum (+)
• black, tarry bowel movements

12. PHYSICAL EXAMINATION
Gen-
Overweight man in moderate distress
VS-
• Blood pressure: 120/62 right arm.
• Pulse rate: 109 (Tachycardia)
• Respiratory rate: 18 breaths per min.
• Temperature: 37.9°C (mild fever)
• Weight: 102 kg
• Height: 5'9‘’ ( BMI- 33.3)- Obese
• Skin: Warm and dry

13. PHYSICAL EXAMINATION
PHYSICAL EXAMINATION
• HEENT: Pupils equal, round, and reactive to light and accommodation Extraocular
muscles intact; discs flat; no AV nicking, hemorrhages, or exudates.
• CHEST: Bilateral rhonchi, faint wheezes
• CARDIOVASCULAR: S1 and S2 normal; no murmurs, rubs and gallops.
• ABDOMEN: Normal bowel sounds and mild epigastric tenderness; liver size normal; no
splenomegaly or masses observed.
• RECTUM: Nontender; melenic stool found in rectal vault; stool heme (+).
• EXTREMITIES: Normal ROM except for restricted right shoulder movement.
• NEURO: CN II–XII intact, DTRs 2 + throughout.

14. SALIENT FEATURE
• “My stomach has been hurting for the past few weeks. Over the weekend, I noticed my bowel
movements were black and tarry.”( Cheif Complaint)
• Age- 62 years (older adults)
• intermittent burning epigastric pain (Right side) & worsen after meal for 2 months
• black, tarry bowel movements for last 3 days
• Bloating(+), intermittent belching(+), nausea after eating(+)
• NSAIDS in MEDICATION HISTORY
• Pulse rate: 109 (Tachycardia)
• Temperature: 37.9°C(Mild Fever)
• Weight: 102 kg (OBESE)
• Smoker & alcoholic
• COPD, Diabetes Mellitus, Osteoarthritis in the right shoulder (Past Medical History)

15. Guide questions
1. What is your initial impression?
2. What are your differential diagnoses?
3. How would you work up the patient?
4. Does the patient need immediate surgery? Why? Why not?

16. INITIAL IMPRESSION
PEPTIC ULCER ( DRUG INDUCED)
• Peptic ulcer disease ( PUD) is a break in the inner
lining of the stomach, the first part of the small
intestine, or sometimes the lower esophagus. An
ulcer in the stomach is called a gastric ulcer, while
one in the first part of the intestines is a duodenal
ulcer.

17. PEPTIC ULCER DISEASE(PUD):
• A peptic ulcer is a sore on the lining of your stomach or duodenum. Rarely, a
peptic ulcer may develop just above your stomach in your esophagus.
• Peptic ulcer can cause perforation (hole) in the intestine which can attract
infection in the abdominal cavity.
• Leads to anemia. Severe loss of blood requires hospitalization and blood
transfusion.
• Severe internal bleeding causes bloody vomit or bloody stool.

18. CLINICAL MANIFESTATION OF PUD
The most common presenting symptom of patients with PUD is epigastric pain (TABLE 3).4
Stomach pain upon food intake is suggestive of a gastric ulcer, while presentation of a
duodenal ulcer includes pain occurring 2 to 5 hours after eating or on an empty stomach
and nocturnal pain. It is relieved by food intake, antacids, or antisecretory therapy.4,5
Chronic ulcers may be asymptomatic and are often NSAID-induced, with UGI bleeding or
perforation being the first clinical manifestation.
Main symptoms-

19. DIFFERENTIAL
DIGNOSIS
❖GASTRITIS
❖PANCREATITIS

20. GASTRITIS
• It is a condition that cause inflammation in the
stomach lining.
• It is caused due to alcohol abuse, injury, infection and
regular use of pain pills.
• Sigh and symptoms include nausea, bloating,
abdominal pain, vomiting, black and tarry stool.
• Antibiotic and antacid helps for the treatment.

21. GASTRITIS
Rule In
Epigastric Pain
Bloating belching,
heartburn
nausea
Black and Tarry stool
Rule out
No despespia
Unintentionally weight
loss(-)

22. PANCREATITIS
• A disease condition characterized by inflammation of
the pancreas.
• It can cause due to alcohol abuse, chronic and caused
by the stone that block the tube leading from the
gallbladder to the small intestine.
• Symptoms include nausea and vomiting, fat in stool,
indigestion, pain in the abdomen.

23. Pancreatitis
Rule In
Epigastric Pain,
tenderness
Severe pain after meal
heartburn
nausea
Fever
Tachycardia
Rule out
Unintentionally weight
loss(-)
Fat or oily stool(-)
Diarrhea
Vomiting (-)
Non-radiated

24. WHY PUD IS
MY INITIAL
IMPRESSION?
• Nausea
• Bloating and Belching
• Burning epigastric pain
• Non radiating
• Long term use of NSAIDs (main risk factors)
• Dark stool
• Alcohol abuse and smoking
• Fatigue

25. Mechanism of
PUD
Ulcers induced by nonselective NSAIDs can occur
due to a topical irritation of the gastric epithelial
cells and reduced protective prostaglandin
synthesis.4 Due to their pharmacologic properties,
many acidic NSAIDs cause alterations in the
hydrophobic mucosal gel layer. The topical
irritation may be the first insult to injury; however,
inhibition of cyclooxygenase (COX) is the greatest
concern. NSAIDs inhibit the rate-limiting enzyme in
the conversion of arachidonic acid to
prostaglandins. COX-2 exists throughout the body,
producing prostaglandins associated with
inflammation and pain, whereas COX-1 is located
in the stomach, kidney, intestines, and platelets.
Isoforms COX-1 and COX-2 are inhibited by
nonselective NSAIDs. As a result of COX-1
inhibition, adverse effects such as ulcers or GI
bleeds may occur.

26. WORK UP FOR PUD
INVESTIGATIONS TO FINALIZE(Lab Diagnostics)
• Upper GI endoscopy
• CBC to check Anemia
• Noninvasive testing of H pylori includes the urea
breath test (UBT), the fecal antigen test (FAT), and
antibody testing.(to rule out H pylori infection)
• X-Ray
• CT-scan

27. TREATMENT
FOR PUD
Medication:
• Promote pump inhalation-
OMEPRAZOLE/PANTOPRAZOLE
• Antibiotics- METRONIDAZOLE, AMOXICILLINE,
CLARITHROMYCIN
• Antacids- MAGNESIUM HYDROXIDE SERUM,
ALUMINIUM HYDROXIDE

28. ❖Follow up(Prevention):-
• Should stop the intake of alcohol and cigarette
smoke.
• Avoid junk and spicy food.
• Consume fruits and vegetables.
• Relaxation techniques like meditation and
exercise.

29. SURGICAL TREATMENT
• Stomach ulcer surgery (as known as ulcer surgery,
gastric ulcer surgery, or peptic ulcer surgery) is a
procedure for treating a stomach ulcer.
• The surgery is used when peptic ulcer disease causes
pain or bleeding that doesn’t improve with non-
surgical therapies.
• The surgeon will identify the source of the bleeding
(usually a small artery at the base of the ulcer) and fix
it.

30. THANK YOU