Feb 5, 2015 - A 66-year-old man was admitted to the hospital with a 2-day history of fatigue, dizzi- ness on standing, and bright red blood from the rectum that ...
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Clinical Problem-Solving Caren G. Solomon, M.D., M.P.H., Editor
A Not-So-Obscure Cause of Gastrointestinal Bleeding Andrew S. Brock, M.D., Jennifer L. Cook, M.D., Nathaniel Ranney, M.D., and Don C. Rockey, M.D. In this Journal feature, information about a real patient is presented in stages (boldface type) to an expert clinician, who responds to the information, sharing his or her reasoning with the reader (regular type). The authors’ commentary follows. From the Department of Internal Medicine, Medical University of South Carolina, Charleston. Address reprint requests to Dr. Rockey at the Department of Internal Medicine, Medical University of South Carolina, 96 Jonathan Lucas St., Suite 803, Charleston, SC 29425, or at r ockey@musc .edu. N Engl J Med 2015;372:556-61. DOI: 10.1056/NEJMcps1302223 Copyright © 2015 Massachusetts Medical Society.
A 66-year-old man was admitted to the hospital with a 2-day history of fatigue, dizziness on standing, and bright red blood from the rectum that transitioned to black, tarry stools. He reported no abdominal pain, nausea, vomiting, or weight loss. He had a history of several myocardial infarctions and subsequent ischemic cardiomyopathy (ejection fraction, approximately 20%); a HeartMate II left ventricular assist device (LVAD) had been placed 2.5 months earlier as destination therapy (i.e., permanent therapy for a patient who is not a candidate for heart transplantation). He also had chronic atrial fibrillation. Medications included warfarin (target international normalized ratio [INR], 2.0 to 3.0), low-dose aspirin, amiodarone, and metoprolol. On physical examination, the patient’s skin and conjunctiva were pale. The heart rate and blood pressure (measured by automated sphygmomanometry) were 74 beats per minute and 117/99 mm Hg, respectively. A continuous hum from the LVAD was heard in the precordial region. The abdomen was soft, with normoactive bowel sounds. Melena was noted in the patient’s bed. There were no stigmata of chronic liver disease. Taken together, this patient’s report of hematochezia and melena and his symptom of orthostatic dizziness indicate clinically significant gastrointestinal bleeding. His heart rate is normal, but this is probably an effect of his cardiac medications, despite volume depletion. Assessment of the stool color (by history taking, examination, or both) is important in clarifying the location and severity of the bleeding. Melena, which results from enteric bacterial degradation of blood, can originate from nearly anywhere in the gastrointestinal tract except the distal colon; red blood from the rectum suggests either a distal source of bleeding or aggressive bleeding from a proximal source. The transition of his stools from red blood to melena indicates that the bleeding probably has a proximal source and has slowed. A careful examination for signs of liver disease, portal hypertension, or both is necessary for all patients with gastrointestinal bleeding. The clinical scenario indicates substantial gastrointestinal blood loss, and the patient should receive immediate supportive measures (volume resuscitation and intensive care monitoring). An intravenous proton-pump inhibitor should be considered, given the possibility of an upper gastrointestinal acid–related disorder. The hemoglobin level was 5.1 g per deciliter (normal value, 12.0 g per deciliter), the hematocrit 16.1%, the platelet count 303,000 per cubic millimeter, the mean corpus-
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n engl j med 372;6 nejm.org February 5, 2015
Clinical Problem-Solving
cular volume 87 fl, the INR 2.1, and the partialthromboplastin time 42.3 seconds (normal range, 23.9 to 36.5). The blood urea nitrogen level was 26 mg per deciliter (9.3 mmol per liter; normal range, 6 to 20 mg per deciliter [2.1 to 7.1 mmol per liter]), and the creatinine level within the normal range, at 1.2 mg per deciliter (106 μmol per liter). Two units of packed red cells were administered, in addition to intravenous fluids. Esomeprazole was also administered, initially in an 80-mg intravenous dose and then as a continuous intravenous drip at a dose of 8 mg per hour. The laboratory data are consistent with substantial gastrointestinal hemorrhage. The elevated blood urea nitrogen level raises the possibility of an upper gastrointestinal source, although it may simply reflect volume depletion. The elevated INR, which is due to warfarin therapy, may exacerbate the bleeding; however, this alone does not cause bleeding, and an underlying lesion should be suspected. Empirical therapy with a proton-pump inhibitor is reasonable in patients with suspected clinically significant upper gastrointestinal bleeding since it may reduce the need for endoscopic therapy for nonvariceal lesions, although endoscopy should not be delayed to allow for the administration of a proton-pump inhibitor. Stabilizing the patient is the first priority, but attention to the differential diagnosis is also needed. Peptic ulcer disease and mucosal inflammation (esophagitis and gastritis) are possible causes. Angioectasias are an important consideration and have been associated with LVADs (especially nonpulsatile devices, such as the one in this patient). Other lesions — including cancer, Dieulafoy’s lesion (an abnormally large submucosal artery), diverticula, and aortoenteric fistula — should be considered but are less likely. Varices are an unlikely diagnosis in this patient given the absence of stigmata of chronic liver disease or portal hypertension. Finally, given the patient’s history of cardiac disease, bowel ischemia must be considered, although this generally causes abdominal pain. In consultation with the patient’s cardiologist, esophagogastroduodenoscopy (EGD) should be planned to help clarify the diagnosis and provide endoscopic therapy if indicated early in his course.
Figure 1. Esophagitis. Esophagogastroduodenoscopy reveals an area just above the gastroesophageal junction with circumferential erosion, exudation, and some areas of bleeding, features that are consistent with severe esophagitis (grade D, according to the Los Angeles classification, in which grade A indicates one or more mucosal breaks of ≤5 mm in length, grade B one or more mucosal breaks of >5 mm, grade C mucosal breaks that extend between two or more mucosal folds but involve
