A 64-Year-Old Woman With Recurrent Gastrointestinal Bleeding

Juan Carlos Munoz, MD; Matthew S. Cole, MD, MPH

Disclosures

March 31, 2016

Physical Examination and Workup

On physical examination, the patient's oral temperature is 98.6°F. Her pulse is regular, with a rate of 107 beats/min. Her blood pressure is 144/70 mm Hg. Significant orthostatic changes are noted in the patient's pulse and blood pressure. Her respiratory rate is 24 breaths/min, with mildly increased work of breathing. She appears pale and cachectic, and her oral mucosa is observed to be dry.

The examination of the head and neck is normal, with no palpable masses or cervical lymphadenopathy. Her lungs are clear to auscultation, but she is tachypneic. Cardiac evaluation demonstrates normal S1 and S2 heart sounds and a mild systolic murmur. The patient's abdomen is protuberant, obese, and soft; no tenderness to deep palpation, rebound, or guarding is noted. Normal bowel sounds are auscultated. The peripheral arterial pulses in the upper and lower extremities are faintly palpable. A venous shunt is palpated in the right upper extremity, with a normal thrill. Rectal examination reveals dark red blood in the rectum. The rest of the examination is unremarkable, except for external hemorrhoids without visible active bleeding.

The initial work-up includes a normal chest radiograph and an ECG showing sinus tachycardia. The remaining findings are nonspecific.

The patient's cardiac enzyme examination is within normal limits. Other laboratory examinations, however, reveal a hemoglobin level of 3.6 g/dL, a hematocrit of 12.2%, a platelet count of 295 × 103 cells/µL, a prothrombin time of 12.3 sec, and a partial thromboplastin time of 22.6 sec. Liver enzyme values are within normal limits. The patient is treated in the emergency department with intravenous fluids, packed red blood cells, and intravenous proton pump inhibitors.

A gastroenterologist is urgently consulted. Emergent upper endoscopy is performed, which does not reveal the source of bleeding. The patient is admitted to the hospital and subsequently undergoes an autologous red blood cell scan, which is also unremarkable.

Anterograde single-balloon enteroscopy with fluoroscopy is performed. This shows an area of active bleeding approximately 160 cm from the incisors. After the area is flushed with tap water, a visible vessel is seen, with normal surrounding mucosa and no evidence of ulceration (Figures 1 and 2).

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