LOWER GI BLEED,A CASE REPORT

DR HAFIZ M. ASAF

DR. M. MAZHAR RAFIQUE

ESW,MHL.

Professor Dr. Haroon Rafi Ul Islam

PERSONAL DATA

• SAJJAD S/O M.ASHRAF

• /19MALE

• PAKISTANI MUSLIM

• DIST. NAROWAL

PRESENTING COMPLAINT

• HISTORY OF DARK TARRY STOOL FOR 11 MONTHS.

HISTORY OF PRESENTING ILLNESS

• MY PATIENT WAS IN USOH WHEN ABOUT 11 MONTHS BACK DEVELOPED MELENA.(2,3 EPISODES/DAY(

• NOT ASSOCIATED WITH FEVER.

• NOT ASSOCIATED WITH HEMATEMESIS, ASCITIS OR ALTERED SENSORIUM.

PAST HISTORY

AT AGE OF 5, PATIENT WAS REPORTED WITH BLEEDING GUMS , FOR WHICH HE GOT TREATMENT AND RECOVERED.

EXAMINATION• A YOUNG MAN LYING ON BED,TOTALLY ORIENTED IN

TIME AND SPACE.

PULSE:104/MIN BP:110/70MMHG R/R :16/MIN TEMP:A/F

EXCEPT VERY OBVIOUS PALLOR GPE WAS NORMAL.

• ABDOMEN WAS SOFT NON-TENDER, NO PALPABLE MASS /HEPATO-SPLEENOMEGALY WAS NOTICED. PR FINDINGS WERE NORMAL.

• CVS,RESPIRATORY SYSTEM,CNS EXAMINTION WAS NORMAL.

WORK UP (DONE AT PIMS)• ALL THE BASELINE INVESTIGATIONS INCLUDING

PLATELET COUNT AND PT,APTT WERE NORMAL. Hb WAS 4.1. (THERE WAS A HISTORY OF ABOUT 40 PINTS OF WHOLE BLOOD TRANSFUSIONS.)

• HBSAG AND ANTI-HCV WERE NEGATIVE.

ENDOSCOPY

• UPPER GI ENDOSCOPY WAS DONE ON 19-9-2013.

• ENDOSCOPY SHOWED “MULTIPLE POLYPS IN DUODENUM”.

• BIOPSY WAS TAKEN.

BIOPSY REPORT

• BIOSPY REPORT ARRIVED ON 25-9-2013, REVEALED “MILD VILLOUS ATROPHY DUE TO MALABSOPTION.

•NO SIGNS OF MALIGNANCY/ DUODENITIS.

COLONOSCOPY

• COLONOSCOPY WAS DONE ON 21-9-2013 AND IT WAS NORMAL.

BARIUM FOLLOW THROUGH

• BARIUM FOLLOW THROUGH WAS DONE ON 18-11-2013.

• IT SHOWED IRREGULAR FILLING DEFECTS IN THE TERMINAL ILEUM. FEATURES SUGGESTIVE OF ILEOCOECAL KOCH’S DISEASE.

• NO DEFINITE CAUSE OF MELENA WAS IDENTIFIED.

CT-SCAN ABDOMEN (WITH AND WITHOUT CONTRAST,26-11-2013)

• LIVER SHOWED NORMAL PARENCHYMAL TEXTURE.

• PANCREAS, SPLEEN AND BOTH KIDNEYS APPEARED NORMAL.

• NO ABDOMINAL LYMPHADENOPATHY SEEN.

• NO FREE FLUID SEEN IN THE PERITONEAL CAVITY.

• HYPER DENSE FOCI SEEN IN THE RIGHT ILIAC FOSSA LYING MEDIAL TO INTERNAL ILIAC VESSELS AND IN THE RIGHT PARA

VERTEBRAL REGION MIGHT BE DUE TO SOME PREVIOUS

INFLAMMATORY PROCESS.

• CONCLUSION:

NORMAL SCAN

MECKEL’S SCAN (2-12-2013)

• THE SCAN REVEALS NORMAL TRACER DISTRIBUTION IN ABDOMEN. FOCUS OF THE ABNORMAL AREA OF RADIOTRACER ACCUMULATION IS NOTED IN RIGHT HYPOGASTRIUM, AT THE SAME TIME WITH UPTAKE IN GASTRIC MUCOSA.

• CONCLUSION:

SCAN EVIDENCE OF ECTOPIC GASTRIC MUCOSA IN RIGHT HYPOGASTRIUM.

ENDOSCOPY AND DUODENAL BIOPSY (12-12-2013)

• “NON-SPECIFIC DUODENITIS ALONG WITH “MILD BRUNER’S GLAND HYPERPLASIA”.

EXP. LAPAROTOMY WAS PLANNED

(06-12-2013)

• THEY WENT FOR LAPAROTOMY WITH HIGH SUSPICION OF MECKEL’S DIVERTICULUM.

• RESECTED ABOUT 90CM ILEUM 2FT PROXIMAL TO ICJ.

• OPERATIVE FINDINGS:

-MULTIPLE ANTI-MESENTERIC PUSTULES OF MUCOSA.

• HISTOPATHOLOGY: (18-12-2013)

-ISCHEMIC ENTERIRIS ASSOCIATED WITH ANGIODYSPLASIA. NEGATIVE FOR MALIGNANCY.

PATIENT AGAIN STARTED TO BLEED!!

• ENDOSCOPY(6-1-2014) WAS DONE SHOWED SMALL POLYPS IN DUODENUM AND BEYOND.

• SUSPICION OF FAP (FAMILIAL ADENOMATOUS POLYPOSIS.

• COLONOSCOPY WAS DONE , WHICH WAS NORMAL.

• PATIENT WAS DISCHARGED ON REQUEST ON 8-1-2014.

PATIENT LANDS IN MAYO HOSPITAL EMERGENCY

DEPARTMENTMARCH-2014

WORK UP AT MAYO HOSPITAL

• ALL BASELINE INVESTIGATIONS WERE DONE AND WERE FOUND TO BE NORMAL EXCEPT HB, WHICH WAS 4.1.

• SERIES ENDOSCOPIES WERE DONE TO RULE OUT ANY UPPER GI BLEED BUT IN VAIN AS THERE WAS NO GROSS ABNORMALITY WAS SEEN IN GASTRIC OR DUODENAL MUCOSA TILL THE DUODENO-JEJUNAL JUNCTION.

• COLONOSCOPY WAS PLANNED AND IT WAS NORMAL TILL ICJ.

99MTC-LABELED RBC G.I. BLEED STUDY(26-03-2014)

• THE CINEMATIC VIEWS REVEAL PHYSIOLOGICAL TRACER ACCUMULATING IN CARDIAC BLOOD POOL,LIVER AND SPLEEN. THE ACTIVITY IN URINARY BLADDER SHOWS EXCRETION OF TRACER THROUGH KIDNEYS.

• THERE IS INCREASED TRACER ACCUMULATION AT THE DISTAL ILEUM. THIS ACTIVITY THEN MOVES IN THE ASCENDING COLON AND TRANSVERSE COLON.

• CONCLUSION:

-SCINTIGRAPHIC FINDING OF THE BLEEDING SITE AT DISTAL ILEUM.

99MTC-LABELED RBC SCAN• NONINVASIVE IMAGING WITH TECHNETIUM-99M (TC-

99M)-LABELED RED BLOOD CELL (RBC) OR TC-99M SULFUR COLLOID SCINTIGRAPHY CAN BE USED TO DETECT AND LOCALIZE GI BLEEDING. TC-99M RBC SCINTIGRAPHY IS 93% SENSITIVE AND 95% SPECIFIC FOR DETECTING A BLEEDING SITE WITH ACTIVE ARTERIAL OR VENOUS BLEEDING RATES AS LOW AS 0.2 ML/MIN, ANYWHERE WITHIN THE GI TRACT. AN ADVANTAGE OF RED CELL SCINTIGRAPHY IS THE ABILITY TO CARRY OUT DELAYED SCANS UP TO 24 H AFTER RADIOISOTOPE INJECTION TO DETECT REBLEEDING. RADIONUCLIDE SCINTIGRAPHY HAS A FALSE LOCALIZATION RATE OF APPROXIMATELY 22%, WHICH LIMITS ITS VALUE AS A DIAGNOSTIC TEST.

PATIENT WAS SHIFTED TO ESW ON

16-04-2014

MANAGEMENT AT EAST SURGICAL WARD

• OPTIMIZATION OF THE PATIENT.

• BLOOD TRANSFUSION WERE ARRANGED.

• OBSERVATION

• PATIENT STARTED TO BLEED ON 20TH APRIL,2014.

BLOOD TRANSFUSIONS

SPWS ARRANGED THE BLOOD WE NEEDED TO OPTIMIZE THE PATIENT.OUR HOUSE OFFICERS DONATED THE BLOOD.AND FINALLY WE MANAGED TO BRING HIS Hb FROM 4gm% TO 11gm%.

CT ANGIOGRAM (RENAL/MESENTERIC/ HEPATIC)

• THERE ARE VERY NORMAL DILATED BLOOD VESSELS WITH EARLY VENOUS FILLING IN THE PROXIMAL JEJUNUM.

• ON THE DELAYED VENOUS PHASE HERE IS CLEARLY EXTRAVASATION OF CONTRAST INTO THIS LOOP SUGGESTING ACTIVE BLEEDING.

• ON THE ARTERIAL PHASE OF THE STUDY THERE IS EARLY FILLING OF MESENTERIC VEINS.

• CONCLUSION:

-ABNORMAL VESSELS NOTED AROUND THE PROXIMAL JEJUNUM WITH EVIDENCE OF ACTIVE BLEEDING LIKELY TO BE RELATED TO ANGIODYSPLASIA.

ESW PLANS EXP. LAPAROTOMY

• WHOLE BLOOD AND FFP’S WERE TRANSFUSED.

• RADIOLOGY AND GASTROENTEROLOGY DEPARTMENTS WERE INVOLVED.

• ON TABLE ENDOSCOPY WAS ARRANGED AND WE WENT FOR EXP. LAPAROTOMY IN EMERGENCY DEPARTMENT OF MAYO HOSPITAL ON 26TH APRIL,2014.

EXPLORATORY LAPAROTOMY

• SURGEON: PROF. DR. HAROON RAFI-UL-ISLAM

ASSISTANT: DR. KHALID MASOOD ALAM

DR. HAFIZ M. ASIF

OPERATIVE FINDINGS• INTRA-OPERATIVE ENDOSCOPY WAS DONE , SHOWED

MULTIPLE ULCERS (OOZING) IN 1FT SEGMENT OF PROXIMAL JEJUNUM.

• ILEUM+COLON WERE FULL OF BLOOD.

• RESECTION AND END-TO-END ANASTOMOSIS OF THAT SEGMENT WAS DONE.

• ON THE GROSS EXAMINATION OF RESECTED SEGMENT CLOTTED/OOZING VESSELS WERE FOUND.

HISTOPATHOLOGY REPORT

HISTOPATHOLOGY REPORT FROM SKMH CONFIRMED IT TO BE ANGIODYSPLASIA OF JEJUNUM.

CURRENT STATUS

• AFTER ABOUT 14 DAYS PATIENT AGAIN PRESENTED WITH EPISODE OF MELENA.

• NUTRITIONAL DEFICIENCIES WERE SUSPECTED.

• VITAMINS ESP. VITAMIN-C SUPPLEMENTS WERE GIVEN ALONG WITH DIETARY IMPROVEMENTS AND PPI.

• MELENA SETTLED.

Pre-OP Post-OP

THANK YOU