Clinical Case: Upper Gastrointestinal Bleed

0
86

A 30 years old male presented to the hospital with blood in vomitus and black tarry stools for the last two days. He was treated for acute hepatitis in 2005 and had no history of ischemic heart disease, hypertension, pulmonary tuberculosis and asthma, also no history of  previous melena, hematemesis, bleeding tendencies & abdominal surgery. There was no history of NSAIDS & anticoagulant intake. The patient had history of Flagyl intake.

Personal History

Non smoker, Non addict

Family History

Mother hypertensive

Socioeconomic History

Satisfactory

Initial Resuscitation

The patient was admitted to the hospital, intravenous access was maintained and pharmacological measures were taken.

The patient was given Inj Risek IV 40 mg x OD, 5% Dextrose  IVI 1000 ml (30-40drops/min), Inj Ceftriaxone IV 1g x 12 hrly, Syp Ulsanic 1tsp (1g) x 8 hrly, Inj Sandostatin IVI 50 micrograms bolus, then 50 micrograms/hr and Inj Gravinate IM 50 mg x stat then SOS.

General Physical Examination

The patient was conscious adult male, lying comfortably in bed well oriented in time, place & person.

  • Blood Pressure:   90/70 mm of Hg (lying), 100/80 mm of Hg (standing)
  • Temperature: 98 F
  • Respiratory Rate: 18/min
  • Pulse: 72/min, regular
  • Pallor  positive
  • Jaundice  positive
  • Pedal edema positive

Cyanosis, clubbing and koilonychia were absent, JVP was not raised and thyroid and lymph nodes were not enlarged.

Abdominal Examination

Abdomen was distended, non tender, hard, umbilicus protuberant, veins visible. Liver, spleen and kidneys were not palpable. Shifting dullness was positive and bowel sounds were present.

Cardiovascular, respiratory and central nervous system examination were not contributory.

Investigations in Upper Gastrointestinal Bleed

Grade IV esophageal varices with portal gastroenteropathy was found on upper GI endoscopy.

HBsAg and Anti HCV antibodies were negative.

Ultrasound abdomen revealed coarse echotexture of liver and moderate ascities. Doppler ultrasound portal and hepatic vein revealed changes in hepatic vein flow. Echocardiography revelaed thin rim of pericardial effusion.

Diagnosis

A diagnosis of chronic liver disease with grade IV varices was made.

Management of Upper Gastrointestinal Bleed

The definitive treatment consisted of:

  • Inj Risek IVI 8 mg/hr
  • Inj Vitamin K IV 10 mg x OD x 3 days (over 1hr)
  • Inj Sandostatin IVI 25 micograms/hr x 3 days
  • FFPs 4 units
  • Inj Cefotaxime IV 1 gm x 08 hrly
  • Foley’s catether
  • Monitoring of urine & vital signs every 2 hrs.

Band ligation was performed.

Upper GI endoscopy with band ligation for esophageal varices images

Post Endoscopy Treatment

  • Inj Novapressin IV 2 mg bolus then 1mg / 6 hr
  • Inj Risek IV 40 mg/100ml x OD
  • Syp Lactulose  3 tsp (10g) x TDS
  • Syp Flagyl 2 tsp x 8 hr
  • Inj Sandostatin IVI 50 micrograms bolus then 50 micrograms/hr
  • Vitamin K IV 10 mg x OD x 3 days

Outcome

After endoscopy patient was stable and afebrile, hematemesis & melena corrected

Follow Up

Patient’s endoscopy was repeated after two weeks. Further investigations to assess hepatic status were carried out.

Patient is recovering and undergoing investigations to find out the exact etiology of chronic liver disease.