Case Abstract

Ruilan, li Female 65y

From: Department of gastroenterology

06/01/2006

Chief complaints

Intermittent hemorrhage in gingival mucosa for one year, epigastric bloating for two weeks and hematemesis for six days

History(1)

Intermittent gingival bleeding for one year, usually during brushing teeth, without rhinorrhagia, petechia, ecchymosis, hematuria,hematochezia, and melena. No therapy.

Middle and upper abdominal floating for two weeks ， accompanied with nausea, no relationship to meal ， without heartburn ， vomitting ， abdominal pain ， hematochezia, and melena. The symptom could not resolve after using Motilium.

History(2)

Hematemesis occurred after taking hot food six days ago, for four times, about 1000ml; accompanied with nausea, vomiting , dizziness, palpitation, fatigue and diaphoresis.

History(3)

At emergency room Vital signs stable CBC: WBC 10.09*10^9,Hgb 101g/l,Plt 77*10^9/l Biochemistry: ALT 35 U/l, Tbil 0.9mg/dl PT+A: PT 16.3s Alb: 2.5mg/dl HbsAg(+) Ultrasonic: spleenomegaly, no abdominal effusion

History(4)

Treated with transfusion, anti-acid, somatostatin at emergency room.

No hemetemesis any more. Endoscopy: esophageal varices , no active

bleeding; chronic gastritis

Past history: deny hepatitis or parasite infection. Personal history ： deny alcohol abuse,

cigarette. Marital and menstrual history: no special. Family history: one daughter HbsAg(+).

Physical examination

vital signs:BP 125/60mmHg, P 85, T 36,R 20; varicosity on abdominal wall, spleenomegaly ， pittable edema on both legs ， palmer erythema (-), spider angiomata （ - ）， shift dullness （ - ） ， flutter trembler （ - ） ， normal on psychological and mental test

Primary diagnosis

Upper gastrointestinal bleeding

esophageal varices rupture

Chronic hepatitis B

hepatocirrhosis

esophageal varices

spleenomegaly

Child B

Chronic gastritis