During my on-call time, a 88 yr old chap came in with 2 bouts of coffee ground vomiting, preceded by a feeling of indigestion.

His background showed

• NSTEMI 4week ago with 12 hr Troponin 2.88
• Angiography  2 weeks ago ( 3 vessel disease: only for medical management in view of co-mobidities)
• 2 storkes (first 1998 with residual Lt weakness, 2nd 2008 with right weakness)
• Multiple TIAs (last time 8 months ago)
• Type 2 DM on Metformin
• Ex-smoker (30 pack years)
• Wheel chair bound

Medications

• Asprin (has been for more than 10 years)
• Clopedogrel (after NSTEMI)
• Ramipril
• Simvastatin
• Metformin

On examination

• Comfortable
• CVS: BP 120/80, P80, Normal heart sounds. No Murmur.
• Resp: Nil significant
• Abd: slight epigastric tenderness. Soft. Normal Bowel sounds
• legs: NAD
• PR: Normal stool

Inv:

CXR: Nil significant

Hb 14.5,

Normal clotting screen, U&E, LFT

Impression:

1. Likely Upper GI bleed as approximately 10% GI bleed incidence among patients with antiplatelets . Haemodynamically stable.
2. NSTEMI 4 week ago
3. Others commodities

Issues:

1. Gastro consultant wont do OGD within 6weeks after MI unless life threatening GI bleed.
2. Interaction with Omeprazole and Clopidogrel

Initial management:

1. Hold aspirin and clopidogrel
2. Repeat Hb (I asked to do in the evening time as first sample was AM)
3. PPI
4. OGD requested (Rockall score 4 in this patient)
5. Observation

Further management:

• Repeat HB dropped more than 10% of its admission level. Melaena stool passed.
• Gastro team agreed to do OGD. but, in next 2-3 days in he was stable.

Discussion:

There are a lot to consider in this kind of patient with MI and GI bleed. Clinical judgement is important for urgent or delayed OGD. PPI is also an issue. In many centre where 24 hr OGD service available, PPI is not recommended before OGD. Moreover, use of IV PPI is restricted, but variable with centres