Dilemma
Dilemma
A 53 year-old man was transferred from an outside hospital where he had been admitted 6 hours earlier because of hematemesis and melena
• A 53 year-old man was transferred from an outside hospital where he had been admitted 6 hours earlier because of hematemesis and melena
Despite transfusion of 6 units of pack red blood cells,his hemoglobin had fallen to 8.8 g/dl. On arrival he was alert and oriented. He denied pain or other problems
• Despite transfusion of 6 units of pack red blood cells, his hemoglobin had fallen to 8.8 g/dl. • On arrival he was alert and oriented. • He denied pain or other problems
He had a remote history of alcohol abuse,but had stopped drinking alcoholic beverages several years ago.He was not taking medication and had not used non-steroidal anti-inflammatory drugs
• He had a remote history of alcohol abuse, but had stopped drinking alcoholic beverages several years ago. He was not taking medication and had not used non-steroidal anti-inflammatory drugs
The physical examination demonstrated pallor,hypotension and tachycardia. There were no stigmata of chronic liver disease
• The physical examination demonstrated pallor, hypotension and tachycardia. • There were no stigmata of chronic liver disease
An nasogastric aspirate showed fresh blood in the stomach. Despite repeated lavage,the aspirate did not become clear
• An nasogastric aspirate showed fresh blood in the stomach. • Despite repeated lavage, the aspirate did not become clear
After stabilization,the patient underwent an emergency endoscopy,which only revealed two oozing Mallory Weiss tears and a large amount of blood in the stomach.There were no ulcers in stomach or duodenum. Soon afterwards,the patient became unstable,requiring volume resuscitation,intubation and pressure support
• After stabilization, the patient underwent an emergency endoscopy, which only revealed two oozing Mallory Weiss tears and a large amount of blood in the stomach. There were no ulcers in stomach or duodenum. • Soon afterwards, the patient became unstable, requiring volume resuscitation, intubation and pressure support
Fresh blood was aspirated from the nasogastric tube.Despite multiple transfusions,his status did not improve. He developed a coagulopathy with a PT of 20 s.In view of the prior endoscopic findings and his tenuous hemodynamic status,the decision was made to perform an
• Fresh blood was aspirated from the nasogastric tube. Despite multiple transfusions, his status did not improve. • He developed a coagulopathy with a PT of 20 s. In view of the prior endoscopic findings and his tenuous hemodynamic status, the decision was made to perform an angiography with potential
Opacification of the superior mesenteric artery showed a massive bleed in the pancreatico- duodenal branch
• Opacification of the superior mesenteric artery showed a massive bleed in the pancreaticoduodenal branch
Rapid contrast extravasation