CASE study: GI bleeding

CASE study by : ທ ສຸກອຸດອນ ເນັ້ງຢ່າ

1.   Patient information : ປ້າມະນີຈັນ 60 ປີ ບ ສີສະຫວາດ  ມ ຈັນທະບູລີ  ຂ ນະຄອນຫລວງ

2.    CC : hematemesis ( ຮາກອອກເລືອດ) ແລະ malena (ຖ່າຍດຳ)       

3.    PMH:

- HTA 3 yr with poor follow up

- No DM

- No allergic

- History of gastric ulcer 2010

4.    PHI:  

Started at  01:00(13/7/13) patient had hematemesis, melena and epigastric pain (no fever, and did’nt not take any medicine)

Then patients was admitted at MAHOSOT HOSPITAL 06:00 morning and take to ICU department at 6:30 because of BP: 80/40 mmHg, p: 110, melena, severe hematemesis(13/7/13).

5.   PE:   good conscious ( speaking , sweating)

Vital sign: BP: 80/40 mmHg, P: 107, t: 38, RR: 23, O2: 95%

HEENT: - conjunctive light pink

Heart :   : s1-s2 regular , no murmur, no cyanosis, no clubbing finger, no JVD

Lung : no retraction,  breath sound : clear

Abdominal :  dry mouth, pain and mass on episgastric (palpation), no distention, TR: black stool

Extreme:  no edema, capillary refill > 2 second, cool extremity.

6.    Problem list : female 60 yr

-       Hematemesis

-       melena

-       epigastric pain

-       mass on episgastric

-       capillary refill > 2 second

-       cool extremity

-       BP: 80/40 mmHg

-       p: 110

7.  Diagnosis

Pre-Shock from GI bleeding

1.   Resuscitation: in the emergency

RL 1l + polyklukin 500 ml ປ່ອຍ 20ml/kg (ປ່ອຍ full)

ຜ່ານໄປ 20-30 ນາທີ ແລ້ວ vital sign: BP:120/80, p: 100-110,

ຍັງສະຕິດີ ແຕ່ເມື່ອຍຫລາຍ, ແຕ່ຍັງມີຮາກເປັນເລືອດປະລິມານຫລາຍປະມານ 1 L ແລະ ຖ່າຍເປັນເລືອດດຳຢູ່. ແລ້ວຈື່ງສົງເຂົ້າ ພະແນກ ICU.

laboratory : CBC

WBC: 6760, Gran: 73%, HB: 6.9, HCT: 20%, PLT: 177, TS: 2, TC: 6

2. ເມື່ອເຂົ້າ ພະແນກ ມໍລະສຸມໄດ້ປີ່ນປົວດັ່ງນີ້: ໃສ່ເລືອດ (10ml/kg/ຄັ້ງ) w: 55kg ໃສ 2 ຖົງ

 - D5NSS 1L

- Omeprazole 40 mg(iv)

- amoxicilline 1g x 2

- flagyl 250mg x 3

- perfalgal ເວລາໄຂ້

- tranxamin (ຢາຫ້າມເລືອດ), ຕິດຕາມອາການຊີວີດ ແລະ ສະພາບທົ່ວໄປຂອງຄົນເຈັບ.

ຫົວຂໍ້ຂອງ GI bleed

1.     Upper GI bleed ອາການ clinic nausa/vomiting, hematesis, ຮາກສີແດງສົດ/ຊ້ຳ, epigastric pain, melena

2.    lower GI bleed ອາການ clinic diarrhea, tenesmus(ຖ່າຍດຸ), ເລືອດອອກທາງອາຈົມສີແດງສົດ, ອາຈົມປົນເລືອດສົດ( hematochezia)

Upper GI bleed:

Peptic ulcer 50%: H.pylori, NSAIDS, gastric hypersecretory state,

Varices 10-30%: esophageal gastric, portal vien HTA,

Gastritis/duodenitis 15%: NSAIDS, ASA, alchoholic, stress, portal hypertensive

Erosive esophagitis/ulcer 10%: GERD, infection (CMV, HSV, or Candida)

Mallory weiss tear 10%

Vascular lesion 5%

Neoplastic disease: esophageal or gastric carcinoma

Oropharygeal bleeding and epistaxis ແລ້ວກືນເຂົ້າໄປ

lower GI bleed:

Diverticular hemorrhagic 33%: 60% ຈະມີເລືອດອອກຢູ right colon

Neoplasia disease 19%: ສ່ວນຫລາຍແມ່ນຈະມີເລືອດກະປີດກະປອຍ ແຕ່ຈະບໍຂ່ອຍຮ້າຍແຮງ

Colitis 18%: infection, ischemic, radiation, inflammatory bowel disease

Angiodysplasia (ເສັ້ນເລືອດຂອງລຳໃສ້ຜິດປົກະຕິ)8% : ສ່ວນຫລາຍຈະພົບທີ່ ລຳໃສ້ໃຫຍ່ທ່ອນຂື້ນ

Anorectal 4%: hemorrhoid, anal fissure, rectal ulcer

Post polypectomy, vasculitis