Case presentation

1. Case presentation 98.5.11

2. Patient profile • Name:翁李X春 • Age: 67 • Gender: female • Chart number: 01011980 • Admitted to our ward on 98.5.2

3. Chief complaint • Tarry stool 3 times today (5/1).

4. 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.

5. 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.

6. 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.

7. 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

8. Personal history • Cigarette Smoking : denied • Alcohol : social • Occupation: 廟祝 • Contact history : Nil • Travel history : Nil • Allergy history: denied • Family history: not contributory

9. Current medication • DM drug from 阮外科 • Metformin 1# bid • Glucobay 1# bid • Denied NSAID and herbal medicine use

10. 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

11. 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(-)

12. Lab data

13. Impression • Hematemesis and tarry stool, suspect upper gastrointestinal bleeding, cause to be determined • Diabetes mellitus type 2, poor control

14. Plan • Arrange panendoscopy • Glypressin 1 amp q6h x 2days • Sugar control

15. 5/1 CXR

16. 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

17. Check HBsAg and anti-HCV • HBsAg = 0.2 (-) • anti-HCV = 25.1 (+) • AFP= 8.0 • Arrange abdominal echo

18. 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

19. CBC follow up during hospitalization 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

20. 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

21. Gastrointestinal bleeding

22. 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.

23. 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).

24. 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.

25. 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

26. 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

27. 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

28. 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

29. 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.

30. Other Causes • erosive duodenitis, • neoplasms, • aortoenteric fistulas, • vascular lesions • including hereditary hemorrhagic telangiectasias (Osler-Weber-Rendu) 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

31. 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

32. 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

33. 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.

36. The end