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ABSTRACT

The report of 77 years old malay woman who presented with vomiting of blood on the day of admission
and history of blackish stool for 3 days duration after admission. She was diagnosed with oesophageal
ulcer due to reflux eosophagitis and gastric ulcer. The subsequent part this report about the clinical
history and the diseases.

Keyword: Upper gastro intestinal bleeding, end stage renal failure, eosophageal ulcer and peptic ulcer.

Introduction

The definition of eosophageal ulcer is the open sore in the lining of the eosophageal. Because of this
condition, it will cause complication later such as bleeding and perforation. This disease usually
associated with acid reflux or known as gastro-eophageal reflux disease (GERD).

This condition occur when the eosophageal lining does not same mucosa lining like in stomach. As the
result, the high amount of acid that refluxing into the eosophageal will damage the eosophageal lining
that leading to eosophagitis and the esophageal ulcer.

The eosophageal ulcer is sensitive to acid secretion. As for treatment, we relieve the symptoms by
reduce the gastric acid secretion by introducing drug known as proton pump inhibitor such as
omeprazole and pantoprazole.

It also believe that this condition was due to Helicobacter pylori, so H.pylori eradication usually was
given to the patient.

Case report

This is a 77 years old woman with background of hypertension and end stage renal failure presented
with vomiting of blood. She vomited of blood about 2 cups of blood, it was fresh blood and a little blood
clot and also a little amount of food particles. This was first episode and It was sudden onset and not
associated with dizziness. In the ward, she experience black stool for 3 day duration, however no altered
bowel habit, fresh blood and foul smelling. Besides, there was no history of trauma prior to this
admission except history of femur fracture due to falling 6 years ago and currently partial independent
with the need use of wheelchairs. Otherwise, there was no syncopal attack, fever, stress ,use of
traditional medicine or painkiller and any pain. The physical examination revealed patient was no
significant finding except the conjunctiva was pale and the arterio venous fistula was functioning on the
the left forearm.The full blood count revealed the haemoglobin was 9 g/dL and renal profle showed she
has hypokalaemic with reading of 2.6 mmol/L. She was diagnose to have esophageal ulcer when she
undergone esophageal gastro duodenal scopy (OGDS ). She was treated by intravenous pantoprazole, 3
pints of normal saline according to patient condition, strict the input and output and control the
comorbidity.
Discussion

Upper gastro intestinal bleeding ( UGIB ) is defined as the bleeding that proximal to ligament of
Treitz. It presented as haematemesis ,malaenic stool , rarely haematozhesia and anaemic. There is
increasing population of UGIB progressively elderly with increase risk of comorbidties that will increase
the mortality. In such case, the mortality will increase with the age more than 60 years old in both sexes1
.

The UGIB can be diagnoses clinically and the most common cause is peptic ulcer. The other
causes are esophagitis, oesophageal varices, acute erosive gastritis, Mallory weis tear,and stomach
malignancy. In case of UGIB, it can manifest as anemia to hypovolemic shock in severe case due to
severe blood loss. It all depend on the rate of blood loss and control of bleeding.

It is very important in history the detail about drug history such as drug non-steroidal anti-
inflammatory drugs (NSAIDS) , anti coagulant such as warfarin and heparin and oral iron therapy will
cause malaena. In physical examination, the sign of hypovolemia should be noted such as high pulse rate
and hypotension. Besides, the stigmata of chronic liver disease may suggestive of oesophageal varices as
the cause of upper gastro intestinal bleeding and epigastric pain should be suspected of peptic ulcer as it
is the most common cause of UGIB and digital rectal examination to rule out any polyps, mass and
malaena.

Peptic ulcer defined as break in the protective lining of the duodenum (the upper part of the
small intestine) or the stomach areas that come into contact with stomach acids and enzymes. It caused
by stress,smoking, alcohol, Helicobacter pylori and overuse of painkiller such non-steroidal anti-
inflammatory drugs (NSAIDS) in case of patient who has always use of painkiller such as endometriosis,
gouty arthritis and stroke. The figure 1 showed the Rockall risk score to identify patient high risk of re-
bleeding from peptic ulcer.

Variable 0 1 2 3
Age (years) <60 60-79 >80
Shock Systolic BP >100 Systolic BP >100 Systolic BP <100
mmHg mmHg mmHg
Heart rate <100 Heart rate >100
bpm bpm

Comorbidities No major Cardiac failure Renal failure Liver


comorbidity Ischaemic heart disease
disease Disseminated
Any major malignancy
comorbidity

Diagnosis MalloryWeiss All other Malignancy of


tear, diagnoses upper
No lesion gastrointestinal
identified, tract
No stigmata of
recent
haemorrhage

Major stigmata of None, Blood in upper


recent Dark spot sign gastrointestinal
hemorrhage tract, Adherent
clot, Visible or
spurting vessel

FIGURE 1:The risk of re-bleeding if the Rockall score is 0 is 5%, and 40% when the Rockall score is >8.

BP: Blood pressure

According to TA Rockall et al, there was 14 % of mortality which consist of 33% for hemorrhage
of inpatients and 11 % of emergency admission. There was 0.8 % mortality for patient under 60 years
old and without malignancy or organ dysfunction 2 . In addition, the risk factors such as age more than
60 years old, severe comorbidity, active bleeding, hypotension and severe coagulopathy are associated
with increase mortality, re-bleeding, the requirement of endoscopic, hemostasis or surgery(3)(4) .

In case of this patient, suspected of stomach malignancy should be consider according the age
which 77 years old, presented with haematemesis and no abdominal pain. However, the patient not
complaint of change in appetite and loss of weight.

The upper gastro intestinal bleeding was increasing among the population of end stage renal
failure compare to general population. This study was done by Wasse H et al which conclude that
smoking, disability to ambulate and cardiovascular disease are higher risk of upper gastro intestinal
bleeding among patient with background of end stage renal failure5
Reference

1.Pilotto A, Maggi S, Noale M, Franceschi M, Parisi G, Crepaldi G. Development and validation of a new
questionnaire for the evaluation of upper gastrointestinal symptoms in the elderly population: a
multicenter study. J Gerontol A Biol Sci Med Sci. 2010 Feb. 65(2):174-8

2.TA Rockall, RF Logan, HB Devlin, TC Northfield: Incidence of and mortality from acute upper
gastrointestinal haemorrhage in the United Kingdom. Steering Committee and members of the National
Audit of Acute Upper Gastrointestinal Haemorrhage. BMJ. 311:222-226 1995.

3. Elmunzer BJ, Young SD, Inadomi JM, Schoenfeld P, Laine L. Systematic review of the predictors of
recurrent hemorrhage after endoscopic hemostatic therapy for bleeding peptic ulcers. Am J
Gastroenterol. 2008 Oct. 103(10):2625-32; quiz 2633.

4. Adler DG, Leighton JA, Davila RE, Hirota WK, Jacobson BC, Qureshi WA, et al. ASGE guideline: The role
of endoscopy in acute non-variceal upper-GI hemorrhage. Gastrointest Endosc. 2004 Oct. 60(4):497-504.

5.Wasse H, Gillen DL, Ball AM, Kestenbaum BR, Seliger SL, Sherrard D, Stehman-Breen CO. Risk factors
for upper gastrointestinal bleeding among end-stage renal disease patients. Kidney intl. 2003 Oct;64
(4)1455-61.
CASE REPORT

UPPER GASTRO INTESTINAL BLEEDING; OESOPHAGEAL ULCER SECONDARY TO OESOPHAGITIS AND


GASTRIC ULCER : A CASE REPORT
1
Amin M.
1
Department of Medicine, Faculty of Medicine and Health Sciences, Islamic Science University
Malaysia, Kuala Lumpur, MALAYSIA

1
Main Author & Correspondence:

MUHAMAD AMIN BIN MUKHTAR (1090255)

Medical Student,

Dept. of Surgery,

Faculty of Medicine and Health Sciences,

Islamic Science University of Malaysia,

Tingkat 13, Menara B, Persiaran MPAJ,

Jalan Pandan Utama, Pandan Indah, 55100 Kuala Lumpur, MALAYSIA.

Mobile: +60132151663

Email: muhamadamin90@gmail.com

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