Physical

• The goal of the patient's physical examination is to evaluate for shock and blood loss.

  • Pulse and blood pressure should be checked with the patient in supine and upright positions to note the effect of blood loss. Significant changes in vital signs with postural changes indicate an acute blood loss of approximately 20% or more.

  • Other signs of shock include cool extremities, oliguria, chest pain, presyncope, confusion, and delirium.

• Hematemesis and melena should be noted which is indicative of bleeding from a gastroduodenal ulcer. The redder the stool, the more rapid the transit, which suggests a large upper tract hemorrhage. Digital rectal examination can be easily performed in the office to check for melena

• During vomiting, the lower esophagus and upper stomach are forcibly inverted. Vomiting attributable to any cause can lead to a mucosal tear of the lower esophagus or upper stomach. The depth of the tear determines the severity of the bleeding.

Lab Studies

• CBC with platelet count and differential: CBC is necessary to assess the level of blood loss. CBC should be checked frequently (q4-6h) during the first day.

• Basic metabolic profile (BMP): The BMP is useful to evaluate for renal comorbidity;

• Prothrombin time/activated partial thromboplastin time

• Liver profile: The liver profile can identify hepatic comorbidity and suggest underlying liver disease.

• Calcium level: A calcium level is useful to identify the patient with hyperparathyroidism as well as to monitor calcium in patients receiving multiple transfusions of citrated blood.

Gastrin level: can identify the rare patient with gastrinoma as the cause of UGIB.

Treatment. Stabilize the patient with intravenous fluids (usually normal saline, except in patients with severe liver disease, ascites, or heart failure) and transfuse to maintain a hemoglobin level of 8-10 g. Promptly correct any abnormalities in coagulation. Baradarian et al demonstrated that early, aggressive resuscitation can reduce mortality in acute UGIB.⁷

The ideal pharmacologic therapy for patients with acute ulcer bleeding appears to be an intravenous PPI.

Surgical intervention usually provides definitive treatment of GOO, but it may result in its own comorbid consequences

• Cancer - Patients with gastric ulcers are also at risk of developing gastric malignancy.

  • The risk is approximately 2% in the initial 3 years.

  • One of the important risk factors is related to H pylori infection. H pylori is associated with atrophic gastritis, which, in turn, predisposes to gastric cancer.

  • H pylori infection is associated with gastric lymphoma or mucosa-associated lymphoid tissue (MALT) lymphoma. The normal gastric mucosa is devoid of organized lymphoid tissue. H pylori infection promotes acquisition of lymphocytic infiltration and often forms lymphocytic aggregates and follicles from which MALT lymphoma develops. Eradication of H pylori is very important in this group of patients because eradication of H pylori has been shown to cause a remission of MALT lymphoma.

• A palpable mass should raise the suggestion of a gastric malignancy.