Gastro Case Challenge: After Routine Procedure, 52-Year-Old Has Black Vomit, Diarrhea

Sarah El-Nakeep, MD


February 27, 2023

The patient was admitted to the intensive care unit, and thrombolytics (recombinant tissue plasminogen activator (rt-PA) were administered. The thrombosis was extensive, therefore surgery could not be performed to remove the gangrenous loops because this would lead to complete removal of the intestine. The ischemic intestinal segment affected more than 90% of the intestine; thus, the two options were either thrombolytic treatment or total bowel resection. The surgeons resorted to thrombolytic medical treatment because the patient was unable tolerate a major operation in her general condition (sepsis and renal affection).

After the patient received rt-PA, her conditioned deteriorated. Her level of consciousness decreased, and she was intubated.

An MRI of the brain showed a small intracerebral hemorrhage (ICH) in the brainstem with surrounding edema. It was inoperable because of her general condition. The patient received conservative medical treatment with brain-dehydrating fluids such as mannitol. She regained consciousness after 1 week; however, she had residual neurologic deficits, including bulbar palsy and weakness on one side.

When her general condition had improved, she underwent partial intestinal resection of the residual gangrenous lesions. Afterward, arterial flow was restored, and in some parts, 50% of arterial flow was regained. The patient is currently receiving total parenteral nutrition (TPN) and is following up with a surgical team, a nutritionist, and a gastroenterologist.


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