00:01
We'll now start our next case.
00:03
We have a 45-year-old man, seen in the ED for
3 episodes of melena in the last 2 days.
00:10
He has not had any
abdominal pain.
00:12
He has no history of bleeding disorders,
alcoholism, chronic liver disease or cancer.
00:18
His medical conditions include
hypertension and prediabetes.
00:22
This is his first
episode of melena.
00:24
He takes high dose aspirin
for chronic knee pain.
00:28
His vitals are notable
for a heart rate of 110,
blood pressure is 125/62 while
supine and 99/55 while standing.
00:37
His abdominal exam is unremarkable
and rectal exam identifies melena.
00:42
Lab studies show a hemoglobin
of 10 but are otherwise normal.
00:47
So what is the best next
step in management?
Let's go through some
key items in this case.
00:53
So he has melena,
he has no significant past medical history
that would place him at risk for developing melena.
01:01
He does, however, have high dose aspirin use
which is a risk factor for GI bleeding.
01:07
And on his exam, this is
notable for resting tachycardia,
and he has orthostatic hypotension as you note
the blood pressure change from supine to standin.
01:17
This indicates that he already has
moderate intravascular volume loss.
01:21
So before we answer the question,
let's go through a differential for him.
01:27
So as we mentioned in
our approach to GI bleeds,
there's a very broad
differential for upper GI bleeds.
01:34
In this case, if we think
through his risk factors,
we know that he has a history of chronic NSAID use
which puts him at risk for gastric or duodenal ulcers.
01:44
Also, he's at risk for erosive
esophagitis, gastritis or duodenitis
Although this is rare, he could
have an arteriovenous malformation
so this should always
be on your differential.
01:58
And although he's fairly young, you should
always put malignancy on your differential
and make sure that you
have ruled it out.
02:04
The other causes listed here
including esophageal gastric varices
or portal hypertensive gastropathy
are less likely in him
because he does not have
a history of cirrhosis.
02:15
In addition, a Mallory-Weiss tear is
also pretty unlikely in this case
because it does not describe a history of
frequent vomiting prior to his bleeding episode.
02:26
So, if we return to our case, we know
that he is a 45 year old man,with melena,
no particular significant past medical history
but he does have high dose NSAID use.
02:37
So the best next step in management includes
recognizing that he has moderate hypovolemia
so the first step, as always, is to fluid
resuscitate and then consult GI for endoscopy.
02:51
Our case now continues.
02:53
The patient is fluid resuscitated, he
has no further episodes of melena.
02:58
He undergoes an upper endoscopy which
does not visualize a source of bleeding.
03:03
He then undergoes a video capsule endoscopy
followed by push enteroscopy as so shown here.
03:10
So first, this is a video capsule endoscopy,
so the patient swallow a small capsule
that then allows us to
visualize the small bowel.
03:20
Here, you see a small amount
of bleeding in the jejunum.
03:25
The next step after doing a video
capsule is to do push enteroscopy
which is a method by which we
can then visualize the small bowel
which is otherwise very difficult to access.
03:36
So here you see an image
from his push enteroscopy
that shows a small area of
angiodysplasia in the jejunum
which probably corresponds to the area
that was bleeding on the video capsule.
03:50
And the next step, he then
undergoes argon plasma coagulation
which is a method of
hemostasis to stop the bleeding.
03:58
And after this vessel is coagulated, he
then has resolution of his bleeding.
04:04
So let's talk a bit about angiodysplasia
or arteriovenous malformations.
04:10
While they are rare, they can
cause up to 47% of GI bleeds
and they're caused by
a vascular abnormality.
04:18
So, as you can see here on the right,
normally a capillary bed is made by
an arterial and a venule coming together,
that's, on top, you can see
a normal blood vessel.
04:29
On the bottom on the other hand, these
blood vessels may form abnormally
and cause an abnormal
connection which is an AVM.
04:38
So patients with AVMs may have
either overt or occult GI bleeding
and usually their bleeding is unmasked by
things like aspirin, NSAIDs or anticoagulants.
04:52
The diagnosis as with all GI
bleeds is done by endoscopy.
04:58
And with endoscopy,
you can also treat.
05:01
So we have various hemostasis interventions
to stop the vessel from bleeding
including injecting epinephrine,
doing coagulation,
or placing a clip on the bleeding
vessel to stop it from bleeding.
05:17
You might encounter the
term "Dieulafoy's lesion".
05:20
A Dieulafoy's lesion is just
a particular type of AVM.
05:25
It refers to a dilated abnormal vessel that erodes
into the epithelium without causing an ulcer.
05:31
It is usually referred to in the proximal stomach
but can really be found anywhere in the GI tract.