Author: Vikram Malladi, MDSeries Editor: Richard Goodgame, MD

Disclosures

March 22, 2005

Case Presentation

A 51-year-old man presented with a 1-day history of hematochezia and melena.

Six months previously, the patient had the acute onset of hematochezia and melena. At that time, he was admitted to another hospital, and received 10 units of packed red blood cells and underwent an extensive evaluation, including upper and lower endoscopy, a radionucleotide red blood cell-tagged bleeding study, and mesenteric angiography. None of these studies revealed the site of bleeding. Small esophageal varices were noted, but no active bleeding or stigmata of recent bleeding was seen. The bleeding stopped and the patient was discharged on propranolol.

Two months prior to this current presentation, the bleeding recurred. He had the acute onset of hematochezia and melena, and was admitted to our hospital after bleeding for several days. Emergency upper endoscopy to the upper jejunum with a pediatric colonoscope showed no blood or active bleeding. There was a small esophageal varix and a small duodenal varix (Figure 1), but no stigmata of recent bleeding.

Mesenteric angiography confirmed portal hypertension with multiple venous collaterals but no active bleeding. Bleeding recurred several times during the hospitalization, but each time it stopped before diagnostic studies were performed. Nineteen units of packed red blood cells were given during the 2-week hospitalization. The only positive study was capsule endoscopy. In a site thought to be the proximal jejunum, the capsule took the photo shown in Figure 2.

Repeat endoscopy with a pediatric colonoscope did not reveal any bleeding or new lesions. The patient was stable and was discharged home. Ten days passed, and he was readmitted with recurrent hematochezia and melena.

His past medical history is positive for heavy alcohol use, cirrhosis diagnosed 1 year ago, and varices, as documented above. He had no other episodes of bleeding or hospitalization other than those reported in the present illness. He has hypertension and mild congestive heart failure. His only medications are propranolol and omeprazole. He is not taking nonsteroidal anti-inflammatory drugs and there is no significant family history. He smokes 1 pack of cigarettes per day.

Physical examination showed normal vital signs after volume resuscitation. He looked well and had no stigmata of chronic liver disease. Cardiac and pulmonary exams were normal. The abdomen showed no organomegaly or abdominal collateral veins. The rectal examination was normal except for maroon stool on the exam finger. The neurologic examination was normal.

Routine laboratory studies were all normal except for a hemoglobin level of 8 g/dL (down from 12 g/dL at prior discharge), a serum albumin of 2.5 g/dL, alanine aminotransferase of 53 U/L, and aspartate aminotransferase of 55 U/L. Coagulation studies were also normal.

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