Case presentation
98.5.11
Patient profile
• Name:翁李X春
• Age: 67
• Gender: female
• Chart number: 01011980
• Admitted to our ward on 98.5.2
Chief complaint
• Tarry stool 3 times today (5/1).
Present illness
• this 67 y/o female was a case of diabetes mellitus type 2
•
•
with medical control at 阮綜合H.
According to herself, she suffered from lower abdominal
cramping pain and yellowish watery diarrhea for recent
days. The symptoms relieved after drug.
However, vomiting with little amount coffee ground 1
time was noted this morning. Then lower abdominal pain
occurred and tarry stool passage 3 times. After this
episode, she felt dizziness and weakness, nausea and
vomiting were still noted.
• Other associated s/s: acid regurgitation(+), chest
tightness(+), palpitation(-), fever(-), chills(-),
constipation(-), hunger pain(-), midnight pain(-), post
prandial pain(-).
• Due to this problem, she was taken to our ER for help.
• At out ER, NG irrigation was done and showed coffee
•
•
ground. lab data revealed severe anemia (Hb=6.7g/dl)
and pre-renal azotemia. PRBC 2U was given for anemia.
Losec 1 vial (自費) was given for r/o upper
gastrointestinal bleeding.
besides, higher blood sugar was also found.
Due to suspect upper gastrointestinal bleeding, she
admitted to our GI ward for further care and treatment.
Past history
• Diabetes mellitus type 2 with medical control for many
•
•
•
years
Hypertension: denied
Heart disease: denied
Hepatitis B/C: denied
– Abdominal echo in MK89: (1)chronic liver disease (2)fatty liver
(3)gallbladder stone
• Peptic ulcer history : denied
• Operation history
– Right clavicle fracture s/p operation
– Bilateral cataract s/p operation
Personal history
•
•
•
•
•
Cigarette Smoking : denied
Alcohol : social
Occupation: 廟祝
Contact history : Nil
Travel history : Nil
• Allergy history: denied
• Family history: not contributory
• Current medication
– DM drug from 阮外科
• Metformin 1# bid
• Glucobay 1# bid
– Denied NSAID and herbal medicine use
Physical examination
• Conscious: Alert, E4V5M6
• Vital sign
– BP:138/64mmHg, PR:115bpm, RR:18pm, BT:36.4 degree
• HEENT
– Conjunctiva: pale, sclera: not icteric
• Neck
– supple, lymphadenopathy(-) jugular vein engorgement(-)
• Chest: symmetric expansion, no spider angioma
– breathing sound: Clear
– heart sound: regular heart beat, no murmur
• Abdomen
–
–
–
–
–
Soft & flat, no caput mdusae
Bowel sounds: normoactive
Muscle guarding(-), tenderness(-), rebounding pain(-)
Liver/spleen: impalpable
CV angle knocking pain: (-/-)
• Lower limbs
– Freely movable, no pitting edema
• Skin
– petechiae/hematoma(-), bedsore/wound(-), skin
rash(-)
Urine routine
Glucose
≧1.0
biochemistry
Bilirubin
-
GOT
87
Ketone
1+
0
GPT
76
SG
1.025
BUN
38.3
OB
-
Crea
1.14
pH
6.0
TP
5.4
Protein
-
alb
3.04
Urobilinogen 0.1
Glu
214
Nitrite
-
Lab data
CBC/DC
Baso
WBC
14.31 Mono
2
RBC
2.46
Lymph
6
Hgb
6.7
PT
11.5
Hct
21.9
PTc
10.7
MCV
89
INR
1.17
UA
7.6
Leukocyte
-
PLT
197
PTT
25.4
Na
138
RBC
0-2
Neut
92
PTTc
28.9
K
4.7
WBC
0-2
Cl
104
Epi
0-2
HbA1c
7.1
Crystal
-
cast
-
eosin 0
Impression
• Hematemesis and tarry stool, suspect
upper gastrointestinal bleeding, cause to
be determined
• Diabetes mellitus type 2, poor control
Plan
• Arrange panendoscopy
• Glypressin 1 amp q6h x 2days
• Sugar control
5/1 CXR
5/2 EGD
• Esophagus
– EV(F2LiCbRC(+-)) with
white nipple sign was
noted near EC junction.
EVL*4 was performed
smoothly.
• Stomach:
– no GV. shallow ulcers was
noted over antrum.
• Duodenum:
– negative finding
• Check HBsAg and anti-HCV
– HBsAg = 0.2 (-)
– anti-HCV = 25.1 (+)
– AFP= 8.0
• Arrange abdominal echo
5/6 abdominal echo
• Liver cirrhosis with splenomegaly
– coarse liver parenchyma, irregular margin
• little ascites
• liver nodule
– S2, hypoechoic, size: 1.3cm
• GB stone and sludge
• suggest follow up echo 3 months later
CBC follow up during hospitalization
5/1
5/2
5/4
5/5
WBC
14.31
17.69
5.04
5.08
RBC
2.46
2.66
3.09
3.2
Hgb
6.7
7.4
8.8
9.2
Hct
21.9
22.7
26.6
27.9
Plt
197
147
112
141
pRBC 2U
Fever without chills and subsided gradually was noted in the afternoon
on 5/4, CRP=18 => suspect temporary bacteremia after EGD
Add prophylactic antibiotic : Ciproxin
Final diagnosis
• Upper gastrointestinal bleeding
– Esophageal varices s/p ligation
• Chronic hepatitis C
• Liver cirrhosis, Child B, suspect hepatitis C
related
• Diabetes mellitus type 2, poor control
Gastrointestinal bleeding
• Hematemesis
– vomitus of red blood or "coffee-grounds" material.
– an upper GI source of bleeding
• Melena
– black, tarry, foul-smelling stool.
– blood has been present in the GI tract for at least 14 h
• Hematochezia
– the passage of bright red or maroon blood from the rectum.
– lower GI source of bleeding, or an upper GI lesion bleed so briskly
• Occult GI bleeding (GIB)
– in the absence of overt bleeding by a fecal occult blood test or the
presence of iron deficiency.
• symptoms of blood loss or anemia
– such as lightheadedness, syncope, angina, or dyspnea.
Source of UGI bleeding
• Independent predictors of rebleeding and death in
patients hospitalized with UGIB include increasing age,
comorbidities, and hemodynamic compromise
(tachycardia or hypotension).
Peptic ulcers
• characteristics of an ulcer at endoscopy provide
important prognostic information
– active bleeding or a nonbleeding visible vessel: clearly benefit
from endoscopic therapy
– clean-based ulcers: rates of recurrent bleeding approaching zero.
• most episodes of recurrent bleeding occur within 3 days
• high-dose constant-infusion IV proton pump inhibitor,
decreases further bleeding (but not mortality), in
patients with high-risk ulcers.
• Prevention of recurrent bleeding
– H. pylori
– NSAIDs
• Combination of a coxib and PPI provides a further
significant decrease in ulcers and recurrent
bleeding and should be employed in very high-risk
patients
– acid
• full-dose antisecretory therapy
Mallory-Weiss Tears
• classic history
– vomiting, retching, or coughing preceding
hematemesis, especially in an alcoholic patient.
• usually on the gastric side of the
•
•
gastroesophageal junction
stops spontaneously in 80–90% of patients and
recurs in only 0–7%.
Endoscopic therapy is indicated for actively
bleeding
Esophageal Varices
• poorer outcomes than patients with other sources of
•
UGIB.
treatment
– Ligation is the endoscopic therapy of choice for esophageal
varices than sclerotherapy
– somatostatin (250 mg bolus followed by 250 mg/h by iv infusion
for five days) further helps in the control of acute bleeding when
used in combination with endoscopic therapy.
• Octreotide and terlipressin (0.4 unit bolus followed by 0.4 to 1.
units/min as an infusion)
– Antibiotic therapy (e.g., quinolones) is also recommended for
patients with cirrhosis presenting with UGIB
• In patients with advanced cirrhosis, intravenous ceftriaxone (1
g/day) may be preferable
– Long term treatment with nonselective beta blockers decreases
recurrent bleeding from esophageal varices
• persistent or recurrent bleeding despite
endoscopic and medical therapy
– Transjugular intrahepatic portosystemic shunt (TIPS)
• hepatic encephalopathy is more common and the mortality
rates are comparable
• shunt stenosis
• most appropriate in patients with more severe liver disease
and in whom transplant is anticipated
– distal splenorenal shunt
• Patients with milder, well-compensated cirrhosis
– Change Anatomy => inappropriate for transplant
• fewer re-interventions
• Surgery risk
Hemorrhagic and Erosive
Gastropathy
• endoscopically visualized subepithelial
•
•
hemorrhages and erosions, not cause major
bleeding
NSAID use, alcohol intake, and stress
Stress-related gastric mucosal injury occurs only
in extremely sick patients
– intravenous H2-receptor antagonist
• more effective than sucralfate but not superior to a PPI
immediate-release suspension given via nasogastric tube.
Other Causes
•
•
•
•
erosive duodenitis,
neoplasms,
aortoenteric fistulas,
vascular lesions
– including hereditary hemorrhagic telangiectasias (Osler-WeberRendu) and gastric antral vascular ectasia ("watermelon
stomach")
• Dieulafoy's lesion
– an aberrant vessel in the mucosa bleeds from a pinpoint mucosal
defect),
• prolapse gastropathy
– prolapse of proximal stomach into esophagus with retching,
especially in alcoholics), and
• hemobilia and hemosuccus pancreaticus
Small-Intestinal Sources of Bleeding
• difficult to diagnose and are responsible for the
•
majority of cases of obscure GIB
Common cause
– in children : Meckel's diverticulum
– In adults <40–50 years : small-bowel tumors
– in patients >50–60 years: vascular ectasias
• Vascular ectasias
– Surgical therapy
– estrogen/progesterone compounds
• no benefit in prevention of recurrent bleeding
Colonic Sources of Bleeding
• The incidence of hospitalizations for LGIB is about one•
fifth that for UGIB.
Common cause
– Hemorrhoids are probably the most common cause of LGIB
– in adults
• diverticula, vascular ectasias (especially in the proximal colon of
patients >70 years), neoplasms (primarily adenocarcinoma), and
colitis
– In children and adolescents
• inflammatory bowel disease and juvenile polyps.
• Treatment
– Medically ,angiographically (Intraarterial vasopressin or
embolization), endoscopically, Surgical therapy
assess a patient with GIB
• Measurement of the heart rate and blood pressure
• hemoglobin values
• clues to UGIB : hyperactive bowel sounds and an
elevated blood urea nitrogen level
• Upper endoscopy is the test of choice in patients with
UGIB and should be performed urgently in patients with
hemodynamic instability
• Patients with hematochezia and hemodynamic instability
should have upper endoscopy to rule out an upper GI
source before evaluation of the lower GI tract.
The end