OSCE — assessment and management of a bleeding peptic ulcer

An 8-minute OSCE station assessing the candidate's structured assessment, Glasgow-Blatchford risk stratification, resuscitation, and definitive management of a patient with a bleeding peptic ulcer. Marks for ABCDE, restrictive transfusion, IV high-dose PPI infusion (80 mg bolus then 8 mg/h for 72 h), dual endoscopic haemostasis, and the stop-NSAID / test-eradicate-H. pylori plan.

Brief (to candidate)

A 68-year-old man who takes ibuprofen for osteoarthritis presents with melaena and dizziness. He is pale, pulse 110/min, BP 96/60 with a postural drop, haemoglobin 78 g/L, blood urea 9 mmol/L. You have 8 minutes to assess him, risk-stratify, and outline immediate and definitive management.^[5]

Candidate instructions

Take a focused history and examine using an ABCDE approach; perform a digital rectal examination for melaena and look for chronic liver disease.
Risk-stratify using the Glasgow-Blatchford score (reproduce its components) and state its purpose.
Outline resuscitation, including transfusion target, IV PPI, and timing of OGD.
Describe endoscopic haemostasis and the post-endoscopy PPI regimen with drug, dose and duration.
State your definitive management: stop the NSAID, test and eradicate H. pylori, and PPI for healing.^[5]

Examiner checklist (mark each domain / 10)

Domain	Key actions expected
ABCDE / resuscitation	Oxygen; two large-bore cannulae; IV fluids; crossmatch; restrictive transfusion to Hb ~70 g/L^[5]
Risk stratification	Reproduces Glasgow-Blatchford components (urea, systolic BP, pulse/heart rate, haemoglobin, melaena, syncope, cardiac/hepatic disease); states it is pre-endoscopy and predicts need for intervention; 0 to 1 may be discharged with outpatient follow-up^[5]
IV PPI + OGD	Starts IV PPI; arranges OGD within 24 h (urgent if unstable); recognises high-risk stigmata
Endoscopic + pharmacological haemostasis	Dual endoscopic therapy (adrenaline injection + thermal/clip) for high-risk stigmata; omeprazole/pantoprazole 80 mg bolus then 8 mg/h for 72 h after haemostasis (Lau 2000)^[5]^[6]
Definitive management	Stop the NSAID; test and eradicate H. pylori (test of cure: urea breath test/stool antigen at least 4 weeks after antibiotics and 2 weeks off PPI); PPI for 8 weeks to heal; review need for gastric-ulcer surveillance^[1]^[5]
Communication & safety-net	Clear plan; reassessment; when to involve surgery/IR for failed haemostasis; safe restart of any anticoagulant

Model key actions

Restrictive transfusion to Hb about 70 g/L; IV crystalloid; group and crossmatch; correct coagulopathy.^[5]
Glasgow-Blatchford high (urea, BP, pulse, haemoglobin, melaena) -> admit and endoscope.^[5]
Dual endoscopic haemostasis + IV omeprazole 80 mg bolus then 8 mg/h infusion for 72 h (Lau, NEJM 2000).^[5]^[6]
Stop ibuprofen, add a PPI, test and eradicate H. pylori (test of cure by urea breath test/stool antigen at least 4 weeks after antibiotics and 2 weeks off PPI).^[1]

Common errors

Liberal blood transfusion; failing to set a transfusion target.
Not using the Glasgow-Blatchford score, or confusing it with the post-endoscopy Rockall score.
Wrong PPI regimen (oral or a single bolus instead of the 80 mg bolus + 8 mg/h infusion for 72 h).
Testing H. pylori while still on a PPI (false negative), or using serology for test of cure.
Restarting the NSAID without gastroprotection; not arranging healing surveillance for a gastric ulcer.^[5]

References3Show

[1]Chey WD, Leontiadis GI, Howden CW, et al. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. American Journal of Gastroenterology, 2017.PMID 28071659
[5]Laine L, Barkun AN, Saltzman JR, et al. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. American Journal of Gastroenterology, 2021.PMID 33929377
[6]Lau JY, Sung JJ, Lee KK, et al. Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers. New England Journal of Medicine, 2000.PMID 10922420

OSCE — assessment and management of a bleeding peptic ulcer

Candidate instructions

Take a focused history and examine using an ABCDE approach; perform a digital rectal examination for melaena and look for chronic liver disease.

Risk-stratify using the Glasgow-Blatchford score (reproduce its components) and state its purpose.

Outline resuscitation, including transfusion target, IV PPI, and timing of OGD.

Describe endoscopic haemostasis and the post-endoscopy PPI regimen with drug, dose and duration.

State your definitive management: stop the NSAID, test and eradicate H. pylori, and PPI for healing.^[5]

Examiner checklist (mark each domain / 10)

Domain	Key actions expected
ABCDE / resuscitation	Oxygen; two large-bore cannulae; IV fluids; crossmatch; restrictive transfusion to Hb ~70 g/L^[5]
Risk stratification	Reproduces Glasgow-Blatchford components (urea, systolic BP, pulse/heart rate, haemoglobin, melaena, syncope, cardiac/hepatic disease); states it is pre-endoscopy and predicts need for intervention; 0 to 1 may be discharged with outpatient follow-up^[5]
IV PPI + OGD	Starts IV PPI; arranges OGD within 24 h (urgent if unstable); recognises high-risk stigmata
Endoscopic + pharmacological haemostasis	Dual endoscopic therapy (adrenaline injection + thermal/clip) for high-risk stigmata; omeprazole/pantoprazole 80 mg bolus then 8 mg/h for 72 h after haemostasis (Lau 2000)^[5]^[6]
Definitive management	Stop the NSAID; test and eradicate H. pylori (test of cure: urea breath test/stool antigen at least 4 weeks after antibiotics and 2 weeks off PPI); PPI for 8 weeks to heal; review need for gastric-ulcer surveillance^[1]^[5]
Communication & safety-net	Clear plan; reassessment; when to involve surgery/IR for failed haemostasis; safe restart of any anticoagulant

Model key actions

Restrictive transfusion to Hb about 70 g/L; IV crystalloid; group and crossmatch; correct coagulopathy.^[5]

Glasgow-Blatchford high (urea, BP, pulse, haemoglobin, melaena) -> admit and endoscope.^[5]

Dual endoscopic haemostasis + IV omeprazole 80 mg bolus then 8 mg/h infusion for 72 h (Lau, NEJM 2000).^[5]^[6]

Stop ibuprofen, add a PPI, test and eradicate H. pylori (test of cure by urea breath test/stool antigen at least 4 weeks after antibiotics and 2 weeks off PPI).^[1]

Common errors

Liberal blood transfusion; failing to set a transfusion target.

Not using the Glasgow-Blatchford score, or confusing it with the post-endoscopy Rockall score.

Wrong PPI regimen (oral or a single bolus instead of the 80 mg bolus + 8 mg/h infusion for 72 h).

Testing H. pylori while still on a PPI (false negative), or using serology for test of cure.

Restarting the NSAID without gastroprotection; not arranging healing surveillance for a gastric ulcer.^[5]

References3Show

[1]Chey WD, Leontiadis GI, Howden CW, et al. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. American Journal of Gastroenterology, 2017.PMID 28071659
[5]Laine L, Barkun AN, Saltzman JR, et al. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. American Journal of Gastroenterology, 2021.PMID 33929377
[6]Lau JY, Sung JJ, Lee KK, et al. Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers. New England Journal of Medicine, 2000.PMID 10922420