PLAB 1 Question Bank

Acute upper GI bleeding from peptic ulceration is the most common cause of significant upper GI haemorrhage in the UK. NSAID use is a major modifiable risk factor, increasing the risk of gastric and duodenal ulceration through prostaglandin inhibition and impaired mucosal defence.

The Glasgow-Blatchford score (GBS) is used at initial assessment to stratify risk. A GBS of 0 identifies very low-risk patients suitable for outpatient management, whereas higher scores indicate the need for inpatient care and urgent endoscopy. NICE guidelines recommend upper GI endoscopy within 24 hours for all patients admitted with upper GI bleeding, and immediately for those with haemodynamic instability or suspected variceal bleeding.

Initial resuscitation follows an ABCDE approach with intravenous crystalloid, blood products as needed, and correction of any coagulopathy. A restrictive transfusion threshold (haemoglobin below 70 g/L) is recommended unless the patient is actively exsanguinating. Intravenous PPI therapy should be commenced following endoscopic haemostasis, not before diagnostic endoscopy. Sengstaken-Blakemore tubes and terlipressin are reserved for variceal bleeding, not peptic ulcer disease.

Remember: In acute upper GI bleeding, resuscitate first with an ABCDE approach, use the Glasgow-Blatchford score to stratify risk, and arrange endoscopy within 24 hours per NICE guidelines.

Primary percutaneous coronary intervention (PCI) is the gold-standard treatment for STEMI. NICE guidelines recommend primary PCI for all STEMI patients presenting within 12 hours of symptom onset, with a target of 120 minutes from first medical contact to balloon inflation. This patient has a clear inferior STEMI based on ST elevation in leads II, III, and aVF, indicating right coronary artery occlusion.

The initial management bundle includes dual antiplatelet therapy with aspirin 300mg and a P2Y12 inhibitor (ticagrelor 180mg or prasugrel 60mg), plus parenteral anticoagulation with unfractionated heparin. High-flow oxygen should only be given if SpO2 is below 94%. GTN and morphine may provide symptomatic relief but do not replace reperfusion therapy.

Thrombolysis is only used when primary PCI cannot be delivered within 120 minutes, for example in rural settings. If thrombolysis is given, the patient should be transferred for rescue PCI if there is less than 50% ST resolution at 60-90 minutes. Exercise testing has no role in acute STEMI management. All STEMI patients require urgent activation of the cardiac catheterisation laboratory.

Remember: STEMI demands primary PCI within 120 minutes of first medical contact - thrombolysis is the fallback only when PCI is not available in time.

NSTEMI management follows the NICE acute coronary syndrome pathway with risk-stratified timing of angiography. This patient has confirmed NSTEMI with dynamic ECG changes and elevated troponin. The GRACE score determines angiography urgency: immediate (within 2 hours) for haemodynamic instability, early (within 24 hours) for high-risk, or within 72 hours for intermediate-risk.

Initial pharmacological management includes aspirin 300mg loading dose, fondaparinux 2.5mg SC (preferred anticoagulant per NICE unless angiography planned within 24 hours), and a P2Y12 inhibitor. NICE recommends ticagrelor or prasugrel over clopidogrel for most NSTEMI patients. Dual antiplatelet therapy continues for 12 months post-ACS.

Thrombolysis is contraindicated in NSTEMI - there is no complete coronary occlusion and it may worsen outcomes. GTN provides symptom relief, and beta-blockers should be started early unless contraindicated. All patients require secondary prevention with high-dose statin, ACE inhibitor, and cardiac rehabilitation referral.

Remember: NSTEMI requires dual antiplatelet therapy plus fondaparinux, with timing of angiography guided by the GRACE risk score - thrombolysis is never appropriate for NSTEMI.