A 47 year old man presents to the emergency room with history of dark tarry stools. He also complains of mild epigastric pain. He suffers from chronic low back pain and takes ibuprofen for the relief of the pain.

1. Which of the following statements about this man is true?
1. The incidence of hemodynamically significant bleeding is high
2. The incidence of anemia is uncommon in this clinical setting
3. The bleeding has a tendency to resolve spontaneously without treatment
4. Upper GI endoscopy is indicated in this case.

Answer: The correct answer is (d). 

This is a case of upper GI hemorrhage induced by Ibuprofen. In such cases the incidence of hemodynamically significant bleeding is not common. It is a rare possibility. The more common presentation is the slow bleed with anemia. The bleeding induced by ibuprofen requires immediate treatment with cessation of ibuprofen and starting anti acid measures. An upper GI endoscopy is indicated in this case.

1. The patient is started on anti acid measures, an upper GI endoscopy is scheduled for the next day and he is sent home. The same evening he returns to the clinic with severe epigastric pain, which did not subside with antacids. He vomited coffee ground material. The immediate step to be taken at this point includes:
1. Immediate exploratory laparotomy
2. Admission to the critical care unit and intravenous omeprazole infusion.
3. Admission to the critical care unit, immediate upper GI endoscopy
4. Reassurance, increase in the dose of medications.

Answer: The answer is (c). 

This man probably has a massive upper GI bleed due to erosion of the gastric mucosa or a mucosal vessel. He needs immediate upper GI endoscopy. In case of hemodynamic collapse he needs immediate blood transfusion. Since the risk for hemodynamic collapse is high in patients who have this kind of precarious bleed, they need to be admitted in the critical care unit and observed.