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Interesting case of GI bleed

Interesting case of GI bleed. Dr Charles Panackel MD DM, Dr Sunil K Mathai MD, DM Department of Gastroenterology, Medical Trust Hospital, Kochi Presenting Author – Dr Sunil K Mathai, HOD Gastroenterology. History. 56 year old female Admitted with Hematemesis - 2 episodes

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Interesting case of GI bleed

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  1. Interesting case of GI bleed Dr Charles Panackel MD DM, Dr Sunil K Mathai MD, DM Department of Gastroenterology, Medical Trust Hospital, Kochi Presenting Author – Dr Sunil K Mathai, HOD Gastroenterology

  2. History • 56 year old female • Admitted with • Hematemesis - 2 episodes • Malena - 3 episodes • Generalized weakness • Giddiness

  3. Admitted to ICU • Hemodynamically stable • PR – 80 / min., BP – 140/70 mm Hg • RT inserted – no fresh blood, coffee ground aspirate • General examination – mild pallor + • Systemic examination – no s/o liver disease • No contributory findings

  4. Urgent Endoscopy

  5. Ulceration with Adherent Clot in Mid Esophagus? Aortoesophageal fistula

  6. Flash Back

  7. Fish bone in mid esophagus in 2005. Active oozing ++ -Referred to MTH

  8. Flash Back CT Chest- Fish bone in mid esophagus piercing aorta Emergency Thoracotomy with aortic repair on 21/03/2005 Uneventful till date…. When she presented with GI bleed on 15/o6/2012

  9. Back to case

  10. CT chest with aortogram

  11. DiagnosisUpper GI BleedAortoesophageal Fistula

  12. How to Manage ?

  13. How to Manage ( what literature says?) High mortality Common cause of death – Exsanguinating Bleed Infection

  14. How to Manage ( what literature says?) 2 main options for Aortic Pseudo aneurysm Open surgery Aortic repair using – Synthetic material Pedicle graft Thoracic esophagectomy + cervical esophagostomy + gastrostomy Endovascular repair

  15. How to Manage ( what literature says?) • Esophageal defect ?? • Leave it alone ?? • Esophagostomy/Esophagectomy ?? • Stenting ??

  16. Endovascular repair Esophageal Stenting PEG for Feeding Antibiotics Plan

  17. Esophageal stenting done

  18. PEG tube for feeding

  19. Follow up aortogram • Both stents well in situ • No obvious leak seen. • Antibiotics • PEG feed

  20. CT Chest after 2 weeks

  21. Follow up • Six weeks • Patient eating well • No infection or leak • Planned for removal of esophageal stent

  22. At Six weeks • At six weeks • Granulation tissue in growth at both ends of esophageal stent. Unable to remove • APC done to ablate the granulation • Still stent could not be dislodged.

  23. Six Months • Both Stents in situ • In growth of Granulation tissue at both ends. Planned for APC

  24. Thank you.

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