Gastroenterology and Hepatology from Bed to Bench

Abstract

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   [1] A 29-year-old man was admitted to the emergency department of Taleghani hospital; a teaching referral hospital in Tehran, Iran, with an acute upper gastrointestinal (GI) bleeding. On admission, he was found to have severe hematemesis since 6 hours before his arrival following an episode of intractable nausea and vomiting. He was single, residing in Tehran, Iran. He had a history of a 10 pack-year smoking, opium addiction and social alcohol consumption but denied usage of other illicit drugs, other medications including NSAIDs and other over-the-counter drugs.  He had a history of stab wound 5 years ago leading to pneumohemothorax requiring a chest tube insertion. He did not mention any melena, defecation and gas passing since 2 days ago. He was not found to have any significant abdominal pain on admission. Four hours post admission, he was still conscious and oriented to the questions we were asking and he was still complaining about severe nausea. He had a temperature of 37.8o C. His blood pressure was 110/75mmHg. He had tachycardia of about 100 beats per minute. Resuscitation with IV fluids started. His physical examination was notable for a mild tenderness in left upper quadrant of the abdomen, dullness to percussion in the left thorax and decreased lung sounds on auscultation in the left lung but the examination of other organs was unremarkable. NG (nasogastric) tube was inserted and fresh bleeding was detected in the tube. His laboratory tests revealed an Hb of 12 gr/dl which was significantly lower than his previous Hb which was documented 18 gr/dl. No leukocytosis and thrombocytopenia was detected. His VBG was within normal limits. Kidney function tests, serum electrolytes, liver function tests, pancreatic enzymes and other biochemical tests were all unremarkable. Being hemodynamically stable but with an ongoing blood loss which demonstrated a serious risk for making him unstable in the near future, an emergent upper GI endoscopy was performed which revealed a completely congested and inflamed mucosa of fundus unable to be inflated in retroflex view. No active bleeding and source of bleeding was detected. Scope could not be passed into the distal part of stomach (figure-1). Abnormal auscultation of the lungs urged evaluation of thoracic field. Chest x ray (figure-2) and thoracic spiral CT scan (figure-3) were demanded.  Six hours post admission, he was found to have tachypnea and shortness of breath. He spiked a heart rate of 120.  

   
   

   What is your diagnosis?

   
   

   What is the next step?

   
   

    

   
   

   Received: 28 May 2020   Accepted: 18 July 2020

   
   

   Reprint or Correspondence: Pardis Ketabi Moghadam, MD. Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

   
   

   E-mail: ketabimoghadam.p@gmail.com

   
   

   ORCID ID: 0000-0001-7110-2950