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Case 164: Collapse

An 82 year old lady collapsed trying to get off the toilet. She had been feeling faint for the past 24 hours.

1. What is this characteristic bowel action called?

Melaena. The passage of altered blood per rectum.

2. How would you manage the problem in the emergency department?

Resuscitation, which includes airway control and breathing assistance if required. Also prompt attention to restoring circulatory volume.

These patients often have other medical comorbidities and a multi-team approach with the intensive care team, and the anaesthetic team is required.

Early referral to the on-call endoscopist and the surgical team is necessary.

Issues are often: anticoagulation, ischaemic heart disease, cardiac failure, liver disease, portal hypertension.

3. What are the options for management?

Early upper GI endoscopy and proceed as required. This lady has several risk factors for higher mortality: her age, and the fact that she collapsed. She requires early and aggressive treatment. Acute upper gastrointestinal bleeding carries a hospital mortality in excess of 10%. The most important causes are peptic ulcer disease and varices.

Varices are treated by endoscopic band ligation or injection sclerotherapy and management of the underlying liver disease.

Ulcers with major stigmata of recent bleeding are treated by injection with dilute adrenaline, thrombin, or fibrin glue; application of heat using the heater probe, multipolar electrocoagulation, or Argon plasma coagulation; or endoclips.

Intravenous proton pump inhibitors reduces the risk of re-bleeding in ulcer patients undergoing endoscopic therapy.

Repeat endoscopic therapy or operative surgery are required if bleeding recurs.

A prospective evaluation of the management of bleeding peptic ulcer.