Case presentationCase presentation

98.5.1198.5.11

Patient profilePatient profile

• Name:Name: 翁李翁李 XX 春春• Age: 67Age: 67• Gender: femaleGender: female• Chart number: 01011980Chart number: 01011980• Admitted to our ward on 98.5.2Admitted to our ward on 98.5.2

Chief complaintChief complaint

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

Present illnessPresent illness

• this 67 y/o female was a case of diabetes mellitus type this 67 y/o female was a case of diabetes mellitus type 2 with medical control at 2 with medical control at 阮綜合阮綜合 H.H.

• According to herself, she suffered from lower abdominAccording to herself, she suffered from lower abdominal cramping pain and yellowish watery diarrhea for real cramping pain and yellowish watery diarrhea for recent days. The symptoms relieved after drug.cent days. The symptoms relieved after drug.

• However, vomiting with little amount coffee ground 1 However, vomiting with little amount coffee ground 1 time was noted this morning. Then lower abdominal ptime was noted this morning. Then lower abdominal pain occurred and tarry stool passage 3 times. After this ain occurred and tarry stool passage 3 times. After this episode, she felt dizziness and weakness, nausea and episode, she felt dizziness and weakness, nausea and vomiting were still noted. vomiting were still noted.

• Other associated s/s: acid regurgitation(+), chest tightOther associated s/s: acid regurgitation(+), chest tightness(+), palpitation(-), fever(-), chills(-), constipationness(+), palpitation(-), fever(-), chills(-), constipation(-), hunger pain(-), midnight pain(-), post prandial pain(-), hunger pain(-), midnight pain(-), post prandial pain(-).(-).

• Due to this problem, she was taken to our ER for help.Due to this problem, she was taken to our ER for help.

• At out ER, NG irrigation was done and showed coffee gAt out ER, NG irrigation was done and showed coffee ground. lab data revealed severe anemia (Hb=6.7g/dl) around. lab data revealed severe anemia (Hb=6.7g/dl) and pre-renal azotemia. PRBC 2U was given for anemia. nd pre-renal azotemia. PRBC 2U was given for anemia. Losec 1 vial (Losec 1 vial ( 自費自費 ) was given for r/o upper gastrointes) was given for r/o upper gastrointestinal bleeding.tinal bleeding.

• besides, higher blood sugar was also found. besides, higher blood sugar was also found. • Due to suspect upper gastrointestinal bleeding, she aDue to suspect upper gastrointestinal bleeding, she a

dmitted to our GI ward for further care and treatment.dmitted to our GI ward for further care and treatment.

Past historyPast history

• Diabetes mellitus type 2 with medical control for manDiabetes mellitus type 2 with medical control for many yearsy years

• Hypertension: deniedHypertension: denied• Heart disease: deniedHeart disease: denied• Hepatitis B/C: deniedHepatitis B/C: denied

– Abdominal echo in MK89: (1)chronic liver disease (2)fatty liver Abdominal echo in MK89: (1)chronic liver disease (2)fatty liver (3)gallbladder stone (3)gallbladder stone

• Peptic ulcer history : denied Peptic ulcer history : denied • Operation historyOperation history

– Right clavicle fracture s/p operationRight clavicle fracture s/p operation– Bilateral cataract s/p operationBilateral cataract s/p operation

Personal historyPersonal history

• Cigarette Smoking : deniedCigarette Smoking : denied• Alcohol : socialAlcohol : social• Occupation: Occupation: 廟祝廟祝• Contact history : NilContact history : Nil• Travel history : NilTravel history : Nil

• Allergy history: deniedAllergy history: denied• Family history: not contributoryFamily history: not contributory

• Current medicationCurrent medication– DM drug from DM drug from 阮外科阮外科

•Metformin 1# bidMetformin 1# bid•Glucobay 1# bidGlucobay 1# bid

– Denied NSAID and herbal medicine useDenied NSAID and herbal medicine use

Physical examinationPhysical examination

• Conscious: Alert, E4V5M6Conscious: Alert, E4V5M6• Vital signVital sign

– BP:138/64mmHg, BP:138/64mmHg, PR:115bpmPR:115bpm, RR:18pm, BT:36.4 degree, RR:18pm, BT:36.4 degree• HEENTHEENT

– Conjunctiva: paleConjunctiva: pale, sclera: not icteric, sclera: not icteric• NeckNeck

– supple, lymphadenopathy(-) jugular vein engorgement(-)supple, lymphadenopathy(-) jugular vein engorgement(-)• Chest: symmetric expansion, no spider angiomaChest: symmetric expansion, no spider angioma

– breathing sound: Clearbreathing sound: Clear– heart sound: regular heart beat, no murmur heart sound: regular heart beat, no murmur

• AbdomenAbdomen– Soft & flat, no caput mdusae Soft & flat, no caput mdusae – Bowel sounds: normoactiveBowel sounds: normoactive– Muscle guarding(-), tenderness(-), rebounding pain(-)Muscle guarding(-), tenderness(-), rebounding pain(-)– Liver/spleen: impalpableLiver/spleen: impalpable– CV angle knocking pain: (-/-) CV angle knocking pain: (-/-)

• Lower limbsLower limbs– Freely movable, no pitting edemaFreely movable, no pitting edema

• Skin Skin – petechiae/hematoma(-), bedsore/wound(-), skin rash(-)petechiae/hematoma(-), bedsore/wound(-), skin rash(-)

Lab Lab datadataCBC/DCCBC/DC BasoBaso 00

WBCWBC 14.314.311

MonoMono 22

RBCRBC 2.462.46 LymphLymph 66

HgbHgb 6.76.7 PTPT 11.11.55

HctHct 21.921.9 PTcPTc 10.10.77

MCVMCV 8989 INRINR 1.11.177

PLTPLT 197197 PTTPTT 25.25.44

NeutNeut 9292 PTTcPTTc 28.28.99

eosieosinn

00

biochemistrbiochemistryy

GOTGOT 8787

GPTGPT 7676

BUNBUN 38.338.3

CreaCrea 1.141.14

TPTP 5.45.4

albalb 3.043.04

GluGlu 214214

UAUA 7.67.6

NaNa 138138

KK 4.74.7

ClCl 104104

HbA1cHbA1c 7.17.1

Urine routineUrine routine

GlucoseGlucose ≧≧1.01.0

BilirubinBilirubin --

KetoneKetone 1+1+

SGSG 1.0251.025

OBOB --

pHpH 6.06.0

ProteinProtein --

UrobilinogeUrobilinogenn

0.10.1

NitriteNitrite --

LeukocyteLeukocyte --

RBCRBC 0-20-2

WBCWBC 0-20-2

EpiEpi 0-20-2

CrystalCrystal --

castcast --

Impression Impression

• Hematemesis and tarry stool, suspect uHematemesis and tarry stool, suspect upper gastrointestinal bleeding, cause to pper gastrointestinal bleeding, cause to be determined be determined

• Diabetes mellitus type 2, poor controlDiabetes mellitus type 2, poor control

Plan Plan

• Arrange panendoscopyArrange panendoscopy• Glypressin 1 amp q6h x 2daysGlypressin 1 amp q6h x 2days• Sugar controlSugar control

5/1 CXR5/1 CXR

5/2 EGD5/2 EGD

• EsophagusEsophagus– EV(F2LiCbRC(+-)) with whiEV(F2LiCbRC(+-)) with whi

te nipple sign was noted nte nipple sign was noted near EC junction. EVL*4 waear EC junction. EVL*4 was performed smoothly.s performed smoothly.

• Stomach: Stomach: – no GV. shallow ulcers was no GV. shallow ulcers was

noted over antrum.noted over antrum.• Duodenum: Duodenum:

– negative findingnegative finding

• Check HBsAg and anti-HCVCheck HBsAg and anti-HCV– HBsAg = 0.2 (-) HBsAg = 0.2 (-) – anti-HCV = 25.1 (+)anti-HCV = 25.1 (+)– AFP= 8.0AFP= 8.0

• Arrange abdominal echoArrange abdominal echo

5/6 abdominal echo5/6 abdominal echo

• Liver cirrhosis with splenomegalyLiver cirrhosis with splenomegaly– coarse liver parenchyma, irregular margincoarse liver parenchyma, irregular margin

• little asciteslittle ascites• liver noduleliver nodule

– S2, hypoechoic, size: 1.3cmS2, hypoechoic, size: 1.3cm• GB stone and sludgeGB stone and sludge

• suggest follow up echo 3 months latersuggest follow up echo 3 months later

CBC follow up during CBC follow up during hospitalizationhospitalization

5/15/1 5/25/2 5/45/4 5/55/5

WBCWBC 14.3114.31 17.6917.69 5.045.04 5.085.08

RBCRBC 2.462.46 2.662.66 3.093.09 3.23.2

HgbHgb 6.76.7 7.47.4 8.88.8 9.29.2

HctHct 21.921.9 22.722.7 26.626.6 27.927.9

PltPlt 197197 147147 112112 141141

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 diagnosisFinal diagnosis

• Upper gastrointestinal bleeding Upper gastrointestinal bleeding – Esophageal varices s/p ligationEsophageal varices s/p ligation

• Chronic hepatitis CChronic hepatitis C• Liver cirrhosis, Child B, suspect hepatitis Liver cirrhosis, Child B, suspect hepatitis

C relatedC related• Diabetes mellitus type 2, poor control Diabetes mellitus type 2, poor control

Gastrointestinal bleedingGastrointestinal bleeding

• HematemesisHematemesis – vomitus of red blood or "coffee-grounds" material. vomitus of red blood or "coffee-grounds" material. – an upper GI source of bleedingan upper GI source of bleeding

• MelenaMelena– black, tarry, foul-smelling stool.black, tarry, foul-smelling stool.– blood has been present in the GI tract for at least 14 hblood has been present in the GI tract for at least 14 h

• HematocheziaHematochezia– the passage of bright red or maroon blood from the rectum.the passage of bright red or maroon blood from the rectum.– lower GI source of bleeding, or an upper GI lesion bleed so briskly lower GI source of bleeding, or an upper GI lesion bleed so briskly

• Occult GI bleedingOccult GI bleeding (GIB) (GIB) – in the absence of overt bleeding by a fecal occult blood test or the prin the absence of overt bleeding by a fecal occult blood test or the pr

esence of iron deficiency.esence of iron deficiency.• symptoms of blood loss or anemiasymptoms of blood loss or anemia

– such as lightheadedness, syncope, angina, or dyspnea. such as lightheadedness, syncope, angina, or dyspnea.

Source of UGI bleedingSource of UGI bleeding

• Independent predictors of rebleeding and death in patieIndependent predictors of rebleeding and death in patients hospitalized with UGIB include increasing age, comonts hospitalized with UGIB include increasing age, comorbidities, and hemodynamic compromise (tachycardia orbidities, and hemodynamic compromise (tachycardia or hypotension). r hypotension).

Peptic ulcersPeptic ulcers

• characteristics of an ulcer at endoscopy provide impocharacteristics of an ulcer at endoscopy provide important prognostic information rtant prognostic information – active bleeding or a nonbleeding visible vessel: clearly benefit active bleeding or a nonbleeding visible vessel: clearly benefit

from endoscopic therapy from endoscopic therapy – clean-based ulcers: rates of recurrent bleeding approaching zclean-based ulcers: rates of recurrent bleeding approaching z

ero. ero. • most episodes of recurrent bleeding occur within 3 damost episodes of recurrent bleeding occur within 3 da

ysys

• high-dose constant-infusion IV proton pump inhibitor, high-dose constant-infusion IV proton pump inhibitor, decreases further bleeding (but not mortality), in patidecreases further bleeding (but not mortality), in patients with high-risk ulcers.ents with high-risk ulcers.

• Prevention of recurrent bleeding Prevention of recurrent bleeding – H. pyloriH. pylori– NSAIDsNSAIDs

•Combination of a coxib and PPI provides a furthCombination of a coxib and PPI provides a further significant decrease in ulcers and recurrent bler significant decrease in ulcers and recurrent bleeding and should be employed in very high-risk eeding and should be employed in very high-risk patients patients

– acid acid • full-dose antisecretory therapy full-dose antisecretory therapy

Mallory-Weiss Tears Mallory-Weiss Tears

• classic historyclassic history– vomiting, retching, or coughing preceding hematevomiting, retching, or coughing preceding hemate

mesis, especially in an alcoholic patient. mesis, especially in an alcoholic patient. • usually on the gastric side of the gastroesophausually on the gastric side of the gastroesopha

geal junction geal junction • stops spontaneously in 80–90% of patients anstops spontaneously in 80–90% of patients an

d recurs in only 0–7%. d recurs in only 0–7%. • Endoscopic therapy is indicated for actively blEndoscopic therapy is indicated for actively bl

eeding eeding

Esophageal Varices Esophageal Varices • poorer outcomes than patients with other sources of poorer outcomes than patients with other sources of

UGIB. UGIB. • treatmenttreatment

– Ligation is the endoscopic therapy of choice for esophageal vLigation is the endoscopic therapy of choice for esophageal varices than sclerotherapy arices than sclerotherapy

– somatostatin (250 mg bolus followed by 250 mg/h by iv infusisomatostatin (250 mg bolus followed by 250 mg/h by iv infusion for five days) further helps in the control of acute bleeding on for five days) further helps in the control of acute bleeding when used in combination with endoscopic therapy.when used in combination with endoscopic therapy.• Octreotide and terlipressin (0.4 unit bolus followed by 0.4 to 1. uOctreotide and terlipressin (0.4 unit bolus followed by 0.4 to 1. u

nits/min as an infusion) nits/min as an infusion) – Antibiotic therapy (e.g., quinolones) is also recommended for Antibiotic therapy (e.g., quinolones) is also recommended for

patients with cirrhosis presenting with UGIB patients with cirrhosis presenting with UGIB • In patients with advanced cirrhosis, intravenous ceftriaxone (1 g/In patients with advanced cirrhosis, intravenous ceftriaxone (1 g/

day) may be preferableday) may be preferable – Long term treatment with nonselective beta blockers decreasLong term treatment with nonselective beta blockers decreas

es recurrent bleeding from esophageal varices es recurrent bleeding from esophageal varices

• persistent or recurrent bleeding despite endoscpersistent or recurrent bleeding despite endoscopic and medical therapy opic and medical therapy – Transjugular intrahepatic portosystemic shunt (TIPS) Transjugular intrahepatic portosystemic shunt (TIPS)

• hepatic encephalopathy is more common and the mortality hepatic encephalopathy is more common and the mortality rates are comparable rates are comparable

• shunt stenosis shunt stenosis • most appropriate in patients with more severe liver disease most appropriate in patients with more severe liver disease

and in whom transplant is anticipatedand in whom transplant is anticipated– distal splenorenal shunt distal splenorenal shunt

• Patients with milder, well-compensated cirrhosisPatients with milder, well-compensated cirrhosis– Change Anatomy => inappropriate for transplant Change Anatomy => inappropriate for transplant

• fewer re-interventions fewer re-interventions • Surgery risk Surgery risk

Hemorrhagic and Erosive GastropHemorrhagic and Erosive Gastropathyathy • endoscopically visualized subepithelial hemorendoscopically visualized subepithelial hemor

rhages and erosions, not cause major bleeding rhages and erosions, not cause major bleeding • NSAID use, alcohol intake, and stress NSAID use, alcohol intake, and stress • Stress-related gastric mucosal injury occurs oStress-related gastric mucosal injury occurs o

nly in extremely sick patientsnly in extremely sick patients – intravenous H2-receptor antagonistintravenous H2-receptor antagonist

• more effective than sucralfate but not superior to a PPI immore effective than sucralfate but not superior to a PPI immediate-release suspension given via nasogastric tube.mediate-release suspension given via nasogastric tube.

Other Causes Other Causes

• erosive duodenitis, erosive duodenitis, • neoplasms, neoplasms, • aortoenteric fistulas, aortoenteric fistulas, • vascular lesions vascular lesions

– including hereditary hemorrhagic telangiectasias (Osler-Weber-Rincluding hereditary hemorrhagic telangiectasias (Osler-Weber-Rendu) and gastric antral vascular ectasia ("watermelon stomacendu) and gastric antral vascular ectasia ("watermelon stomach") h")

• Dieulafoy's lesionDieulafoy's lesion– an aberrant vessel in the mucosa bleeds from a pinpoint mucosaan aberrant vessel in the mucosa bleeds from a pinpoint mucosa

l defect),l defect),• prolapse gastropathyprolapse gastropathy

– prolapse of proximal stomach into esophagus with retching, espprolapse of proximal stomach into esophagus with retching, especially in alcoholics), andecially in alcoholics), and

• hemobilia and hemosuccus pancreaticushemobilia and hemosuccus pancreaticus

Small-Intestinal Sources of Small-Intestinal Sources of BleedingBleeding

• difficult to diagnose and are responsible for thdifficult to diagnose and are responsible for the majority of cases of obscure GIBe majority of cases of obscure GIB

• Common cause Common cause – in children : Meckel's diverticulum in children : Meckel's diverticulum – In adults <40–50 years : small-bowel tumorsIn adults <40–50 years : small-bowel tumors– in patients >50–60 years: vascular ectasiasin patients >50–60 years: vascular ectasias

• Vascular ectasias Vascular ectasias – Surgical therapy Surgical therapy – estrogen/progesterone compounds estrogen/progesterone compounds

• no benefit in prevention of recurrent bleeding no benefit in prevention of recurrent bleeding

Colonic Sources of BleedingColonic Sources of Bleeding

• The incidence of hospitalizations for LGIB is about onThe incidence of hospitalizations for LGIB is about one-fifth that for UGIB. e-fifth that for UGIB.

• Common causeCommon cause– Hemorrhoids are probably the most common cause of LGIB Hemorrhoids are probably the most common cause of LGIB – in adultsin adults

• diverticula, vascular ectasias (especially in the proximal colon of diverticula, vascular ectasias (especially in the proximal colon of patients >70 years), neoplasms (primarily adenocarcinoma), and patients >70 years), neoplasms (primarily adenocarcinoma), and colitiscolitis

– In children and adolescentsIn children and adolescents• inflammatory bowel disease and juvenile polyps. inflammatory bowel disease and juvenile polyps.

• TreatmentTreatment– Medically ,angiographically (Intraarterial vasopressin or embMedically ,angiographically (Intraarterial vasopressin or emb

olization), endoscopically, Surgical therapy olization), endoscopically, Surgical therapy

assess a patient with GIB assess a patient with GIB

• Measurement of the heart rate and blood pressure Measurement of the heart rate and blood pressure • hemoglobin values hemoglobin values

• clues to UGIB : hyperactive bowel sounds and an elevaclues to UGIB : hyperactive bowel sounds and an elevated blood urea nitrogen level ted blood urea nitrogen level

• Upper endoscopy is the test of choice in patients with Upper endoscopy is the test of choice in patients with UGIB and should be performed urgently in patients wiUGIB and should be performed urgently in patients with hemodynamic instabilityth hemodynamic instability

• Patients with hematochezia and hemodynamic instabPatients with hematochezia and hemodynamic instability should have upper endoscopy to rule out an uppeility should have upper endoscopy to rule out an upper GI source before evaluation of the lower GI tract. r GI source before evaluation of the lower GI tract.

The endThe end