So next patient is quartly quartly q u a r t l y thunchinok t h u n c h a n o k 781434 50 year old lady investigations december 2024 well upper gi endoscopy october 2024 as an inpatient on allotrin for molina clean based pyloric ulcer and then rescope december 2024 demonstrating ulcer is healed so past medical history upper gi bleed due to peptic ulcer october 2024 primary hyperparathyroidism hemoglobinopathy duodenal ulcer breast cancer so she had left breast cancer treated with neoantigen chemotherapy with nipple and skin sparing mastectomy implant reconstruction and axillary node clearance 20 23 radiotherapy in 2024 and hepatitis b 2014 for treatment referral is because of treatment resistant reflux too young for 2 week wait protocol reflux dark or in stools so investigations ferritin of 44 with full blood count hemoglobin of a 140 with mcv 75.8 fit less than 5 h pylori stool antigen test october 2025 detected it looks like she had a parathyroidectomy in june 2025 for a parathyroid adenoma her biopsies of the stomach from october 2024 no helicobacter pylori detected at that time come on in please have a seat thank you hi courtney I'm rob I'm 1 of the gastroenterology doctors nice to meet you nice to meet you how are you I'm okay thank you good I'm glad I hear from your gp you've had some upper tummy pain yes tell me all about it you mean how long ago a few months ago now isn't it yeah I mean basically it went back to when she was doing well when when she was going through the chemo she had a bleed and I read about it you were on our ward when I was in yeah and that that you know was sorted out but then she had a bleed the other well a month or so ago now and it stayed black even after the what was it whatever do you know the tablet yeah tablet the metrazole metrazole yeah yeah she had a course of that so what happened to you had another bleeding episode you think well you tell me about it yes they have like dark dark yeah it's black it's like this polo shirt and slimy yeah you know black and shiny fine when was this 6 8 weeks ago yes and it went on like about 3 4 weeks yes right before I contact gp been for a long time and before that it was a while mhmm yeah yeah but now they're okay now fine good and now brown yeah now back to normal yeah yeah yeah good yeah and your gp did some blood tests is that right at that time yeah and your blood counts were fine which is good your cells are a little small maybe you're iron deficient because of the bleeding okay but your body is producing enough cells which is good and then you had a stool test looking for an infection yeah with h pylori yeah she had was positive and then did we do anything about that it was 2 lots of antibiotics okay I can't remember which which 2 there but it was fine and you had those for the week yeah took them good for the course yeah and did that improve the symptoms at all that time no no it didn't they were still coming out yeah black mhmm and tummy pain before yeah before but now but now since good so during that time there was palpate pain fine mhmm and feeling dizzy lightheaded chest pain shortness of breath anything like that no good fine I'm glad so you're you've had a lot going on this year haven't you mhmm the breast cancer in the recent past and then parathyroid that's right yeah parathyroidectomy yeah yeah poor thing you're a lot isn't it absolutely I know you I can see you're very strong funny enough she didn't actually stop working really she was coming out of a chemo and going back to work what do you do for a living she's got her kra yeah she's got her own little business and lovely but older people younger people and older people mhmm but they look after me they look after you sounds fine okay that sounds good but they didn't they didn't know I have cancer I didn't tell them yeah I just said after chemo I got headache mhmm they just look after me oh that's nice fine and do you drink or smoke no neither of those cleaning fine when you had your endoscopy back in october when you were in hospital yeah we didn't detect any of the infection no heat h pylori at that time no k but h pylori is difficult for us it you you acquire it sometime in childhood oh okay yeah and you have it all through your life oh okay the treatment that we give sometimes gets rid of it but sometimes it comes back yeah yeah yeah tests for it are not very good the biopsies the sensitivity is 70% so only if you if 100 people had h pylori and you biopsied all of their stomachs only 70 of them would come back positive 30% would be false negatives other tests and when you're on the anti acid medicine the sensitivity of the test decreases further so it's a challenging thing to detect and it's a challenging thing to treat because it sometimes doesn't respond completely to the initial course of treatment we give we care because it causes symptoms you get tummy pain it causes ulcers in the stomach and over time it's a risk factor for stomach cancer so we worry about that and we want to eliminate it sorry life is dormant then exactly because to be honest I did read up on it it basically says that it was something really from a while back there's not that many cases exactly over here yeah exactly that would that would sort of add up because obviously being in thailand mhmm yeah you know completely it's likely that you picked it up where you were very small yeah and there you know there the the incidence and prevalence of it is higher yeah outside of the uk yeah lots of people in eastern and central europe have it oh okay and then as you say east asia is also very common mhmm so it could be cancer I don't think you have cancer uh-huh but the infection yeah over years and years and years can cause can lead to cancer which is why we want to get rid of it yeah mhmm does that make sense okay yeah so the the best test we have is a biopsy of the stomach to look for it when you're on anti acid medicine the omeprazole it drives the h pylori deeper into the stomach wall and we can't get to it okay right so you probably had some anti acid medicine when you came into hospital bleeding mhmm the biopsy didn't detect it and it may have been that you had it since then mhmm okay possibly yeah mhmm do you take antacid medicine in the long term or do you no no no what's the antacids omeprazole oh I know so mhmm yeah don't take about 1 month 1 month that's it you you did have 2 lots didn't you because yes yeah the doctor prescribed 2 2 lots and then at the month 6 week yeah yeah but then but then once how long ago finish that you stop yeah yeah yeah yeah but how long ago was that thing you think it must be about a month no about a month ago I think she stopped okay alright good it's difficult to get on the dates no no you've got a lot going on so I understand completely I think when we saw you last and you had your last endoscopy back in december we suggested would suggest maintenance ppi long term last year did you we we were thinking you had an ulcer yeah yeah yeah we haven't found a cause for the ulcer so maybe you should go on long term antiacid medicine now you've had some treatment for h pylori so that's good and that may have been the cause if you've if you've bled I think it would be sensible to have another look with another camera test okay that sound alright another 1 of these endoscopies yeah she didn't like it no no she doesn't you had it the 1 in the 1 in december that was '24 2024 yeah last year because that was sort of a thing okay had some sedation yeah that one's awful 1 last 1 that 1 was awful oh I'm sorry I think he gave me overdose with sleeping I think you went too sleepy no and can't I can't wake up and now I'm feeling sick I yeah remember now I came to collect you and you were sick mhmm so wait another hour and you're sick they wanna get rid of the we finally got out well she got on the lawn she was sick on the lawn so sleepy and feeling sick and headache I a few hands in there oh sorry they're strong medicines that we use yeah and then the first 1 in october how did you find that that one's not bad you had less medicine that time mm-mm a little less that's similar amount because they can't walk go home is they can't walk I sit waiting area for a long time mhmm and then you wanna sleep all the time you see of course yeah feeling sick is awful yeah strong medicines yeah the other option I guess is to try with very minimal sedation or with no sedation at all that maybe a third of the procedures that we do we do with no sedation just with spray at the back of the throat yeah fair enough I understand even the spray tastes horrible yeah it does taste horrible I know it's not a nice test I guess the concern is if you have another gastric ulcer it's good to look at it yeah fair enough work out what is causing it take some biopsies make sure there's nothing sinister and have a good careful look at your stomach because of the symptoms you're having mhmm yeah we want to make sure we get rid of the h pylori completely and sometimes it takes several courses of antibiotics to help keep the kidneys up yeah so it's good that your symptoms have got better mhmm and it probably means that it's all better but mhmm it'd be good to be sure I think yeah yeah I think you stopped the antacid now for omeprazole stop yeah that like I said about a month ago sorry oh you stopped a month ago yeah yeah I'd at least 1 month I'll book it for you quite urgently is that okay we'll get it in the next couple of weeks 2 weeks or something like that is we're hoping yes and her mom is well she's 90 in thailand without the mask however so she wants to go home for you know she's she's been at bay so we're hoping to go that's why don't think with anything yet I want to go to hana as soon as possible as soon as possible yeah yeah but it's possible so a couple weeks is okay wouldn't it yes not fine but I mean yeah there's probably and will you be in tidal for a while I guess 4 weeks I thought oh only yeah it's not too far yeah yeah I'll book the camera test for you we'll see the results of the camera test if it shows more h pylori we can give you another course of treatment yeah and we can have a careful look at your stomach oh that's fine does that sound okay think once you've had once you're conferring cancer every every little thing now it always goes back to the first thing in your head is also stomach cancer yeah I think it's all natural I don't think you have that no well that's what the gps because here was fine and it was only a year ago it takes more than a year to develop a stomach cancer don't worry okay you can't not not thinking because when they have breast cancer I never ever expect that I laughed with the doctor when they said they have cancer I said no but I'm a live big lady yeah you know healthy I'm going to see him 5 times a week wow and my family never ever have cancer and how come does it got cancers I don't believe that cancer I know so I just couldn't believe it you know what happened so but now I'll be careful you know of course yeah she got quite excited after a while because she thought she could go up to c or d cups she just seems like ordering could have know but don't give that to me I did I did find it for doctor yeah I did say 11d and 1 a would look a bit odd yeah and then doctor asked me you know are you still thinking that because they said come after year and if you don't have it then I went to check up with mister green after the year he said he said you can have the other 1 you know bigger 1 he's I'm not gonna get you some no more operation don't let me it's horrible isn't it yeah it is really horrible could we get some more blood tests today is that alright you may find it difficult because no 1 can ever get blood out of her she's been going to what's it called vascular yes yes I had to go that place I mean even when she went through the cancer sometimes they were trying 8 9 times oh wow and they didn't take the blood and they still have the chemo they used the previous apparently she's got very very small veins I mean she has had it taken a few times but I would say 50% of the time they just kinda get it after like 6 7 8 goes I nearly faint because I don't like needing them of course but the team here are very good yeah they're very good they do a lot of difficult 1 time they're they're 1 shot and they're done you see they ask yeah with vascular services they always it don't matter you suffer you don't have to guess I'm not keen on needles when I'm in the ring we're there come on you're right I'm looking at the ceiling so we have a plan yeah blood test today if we can yeah and I'll get you an endoscopy in 2 weeks in the next 2 weeks fantastic yeah and we'll take it from there yeah okay I'm sorry I know it's not what you wanted no but it's important to make sure we get rid of this for you yeah yeah did they weigh you today no that's fine she had a she weighed herself every day about you no I'm not weighed myself think last time we went to what's her the hospice what do you call it oh went to run run she had a fever thank you so much pleasure to meet you if you go all the way down here yeah you see where the people are sat and then move from it and just sit just past it okay so diagnosis recurrent gi bleeding likely secondary to peptic ulceration in the context of positive h pylori h pylori eradication undertaken now off ppi for 1 month plan: <\n> Number 1 upper gi endoscopy 2 week wait number 2 blood test today <\n\n> Did you pee, <\n> I had the pleasure of meeting missus thunkenok in iron deficiency anemia clinic today on behalf of doctor poles full stop the consultation is face to face and she was accompanied by her partner full stop <\n\n> It sounds as though she's had an episode of melena 6 to 8 weeks ago which lasted 3 to 4 weeks and is associated with epigastric pain full stop reassuringly this is now resolved she's passing a brown stool she had some blood tests with you which did demonstrate microcytosis but without anemia and she also had an h pylori stool antigen test which is positive full stop thank you very much for prescribing her 1 week of eradication treatment for that full stop her upper abdominal pain is resolved and as I said her stools have turned brown again which is obviously reassuring in terms of ongoing bleeding full stop <\n\n> In terms of her life more generally she works as an elderly carer she doesn't drink or smoke she goes to the gym 5 times a week her performance status is 0 we'll start <\n\n> We discussed today that it's likely that she has had a further peptic ulceration secondary to helicobacter pylori and we'd suggest a further upper gi endoscopy in order to investigate this in more detail as well as considering long term antacid treatment as advised in the previous endoscopy back in october to prevent any further ulceration we could recheck her phag pylori at this time as she's been off ppi now for a month and if this is positive we could prescribe a further second line eradication treatment she's reluctant to have an upper gi endoscopy which is understandable because she says that her last endoscopy where she received 75 micrograms of fentanyl and 3 mg of midazolam she was dizzy on her feet after and vomited several times I would suggest that we give her lighter sedation this time in order to prevent any sedation related side effects after full stop <\n\n> In addition to the upper endoscopy which I request for her 2 week weight she is also gonna have some blood tests due to recheck hemoglobin and her urea and I look forward to seeing the result of these full stop yours sincerely <\n\n> On examination height 52 cent kilograms a height of hundred and 55 cm