A 70YearOld Man with Hematemesis

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A 70-Year-Old Man with Hematemesis
Eugene G. Martin, Ph.D. Associate Professor of
Pathology Laboratory Medicine and Roy Rhodes,
M.D.Associate Professor of Pathology
Laboratory Medicine

• Based upon LABORATORY MEDICINE CASEBOOK. An
  introduction to clinical reasoning
• Jana Raskova, MD Professor of Pathology
  Laboratory MedicineStephen Shea, MD
  Professor of Pathology Laboratory
  MedicineFrederick Skvara, MD Associate
  Professor of Pathology Laboratory MedicineNagy
  Mikhail, MD Assistant Professor of Pathology
  Laboratory MedicineUMDNJ-Robert Wood Johnson
  Medical SchoolPiscataway, NJ

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History

• 70 year old male admitted to the hospital with a
  chief complaint of hematemesis of several hours
  duration
• Indicates that he awoke during the night with
  nausea and vomiting of bloody material.
• He has taken one aspirin per day for several
  years. In the last few days, he had taken
  ibuprofen for leg pain.
• He remembers passing a dark stool for several
  consecutive days.
• He denies alcohol consumption
• Quit smoking 10 years earlier
• No other medical or surgical history and he
  claims to be in good health

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What questions does this history elicit?

• 26 million Americans take 80 mg/day as a
  precaution against a heart attack
• If he has significant arthritis, he may be taking
  300 mg/day and the addition of ibuprofen will
  certainly increase the risk of side effects
• Deep vein thrombosis is always a consideration.
  Pain can lead to vomiting (albeit not of blood).

• Was he taking 300 mg or 80 mg per day of ASA?
  Why?
• What is the leg pain thats being described?
  Could it be significant?
• What is the significance of the dark stool?

Ibuprofen Stomach pain Vomiting, Bloody
vomiting Tarry stools Extremity swelling
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Analgesics

• Contraindications to ASA therapy
• Have a history of peptic ulcer, liver or kidney
  disease
• Have uncontrolled high blood pressure
• Any bleeding disorder
• Have GI bleeding
• Are taking warfarin (Coumadin)
• Are allergic to aspirin

• Side Effects of ASA
• Repeated use may cause gastrointestinal bleeding
• Large doses can provoke a host of reactions
  including vomiting, diarrhea, vertigo and
  hallucinations.
• The average dose is 300 mg single doses of 10-30
  g can be fatal.

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Physical findings

• Physical Exam
• Well nourished man in acute distress due to
  persistent nausea.
• BP 130/90 supine 100/75 standing
• HR 104 bpm
• Temperature 97.6 oC
• Respiratory rate 16 per minute
• Abdomen soft and non tender with active bowel
  sounds
• No masses were felt.
• Rectal exam Stool positive for occult blood
• Fresh blood noted in the body and cardia of the
  stomach.
• Esophagus and duodenum normal
• Bleeding lesion could not be identified.

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Questions from the physical

• What is the significance of determining a supine
  and a standing BP?
• Is the HR 104 bpm significant?
• What is the importance of being guaiac positive?

• Does this patient have orthostatic hypotension?
  (Defn A fall in BP gt 30/20 on standing). Answer
  YES
• One of the consequences of blood loss is an
  inability to maintain blood pressure upon
  standing. One of the physiologic responses is an
  increase in HR.
• Acute blood loss ? ? RBC count, ? HCT and ? Hgb ?
• ? HR, orthostatic hypotension, ? RR
• Guaiac is a screening procedure for occult blood.
  Food intake, (red meats false positive)
  Vitamin C intake false negative,

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HEMATOLOGY
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Peripheral Blood Smear
Patient
Normal

• Normochromic, normocytic anemia.
• Red cell population is decreased in number
• Cell size and shape normal
• Platelets and neutrophils are unremarkable
• None of this information adds anything to the
  automated hematology count shown earlier

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Questions from the Hematology Results

• With a Hgb of 7.8, the Hct could not be 34 if
  this patient had a normochromic, normocytic
  anemia. (Hct should be 24)
• Choice 1 Lab error.
• Choice 2 Hct is not reliable as an estimate of
  anemia immediately after acute blood loss.
• Normochromic, normocytic anemia
• Reticulocyte ?
• Hemolytic disease
• Acute blood loss
• Reticulocyte normal
• Malignancy
• Myeloma
• Chronic Disease
• If this patient had a chronic blood loss for more
  than 6 months you would expect a hypochromic,
  microcytic anemia

• There is an anomaly in the hematology values
  can you spot it?
• Does this patient have anemia? If so, what kind?
• Is this a serious blood loss?
• SUMMARIZE
• Acute blood loss
• Significant hypotension
• Calls for rapid stabilization with volume
• Is this blood loss sufficient for a whole blood
  transfusion?

Hgb X 3 Hct Sources of error for
Hct Improper centrifugation Posture, muscular
activity Failure to mix blood adequately
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Anemia Assessment

• ?Normocytic, normochromic anemia
• Reticulocyte ?
• Hemolytic disease
• Acute blood loss
• Reticulocyte normal
• Malignancy
• Myeloma
• Chronic Disease
• Macrocytosis is seen in
• Megaloblastic anemias ?
• vitamin B12 and folate deficiency
• Some forms of chronic liver disease
• Microcytosis and hypochromia
• Iron deficiency anemia
• Spherocytosis
• Some forms of anemia of chronic disease

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Guideline and Policies for Transfusion

• Basic Concept
• Give blood when it is really necessary
• Give the patient only what is needed.
• Packed RBC
• Hgb lt8-10 g/dl, Hct lt 0.25-0.30 (PATIENT Hgb
  7.8 g/dL, Hct 24 )
• Active bleeding with hypotension and tachycardia
• This patient probably qualifies for PRBCs
• Whole Blood
• Volume 450-500 ml
• Contents
• RBCs, 200 ml
• Plasma, 250 ml
• Nonfunctional WBCs and platelets
• Anticoagulants, 63 ml
• 200mg iron
• Emergency Situation ONLY trauma, massive
  bleeding
• Minimum 3 unit transfusion

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Differential - Upper GI bleeds

• 90 of upper GI bleeds are accounted for by
  erosive gastritis, duodenal ulcer, gastric ulcer
  and esophagastric mucosal tears

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CHEMISTRY/URINALYSIS
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Why is

• BUN - 45 mg/dL
• What are the sources of BUN?
• Does this patient have primary kidney disease?
  Why? Why not?

• Primary sources of blood urea nitrogen are
• GI bleeding ?
• Black tarry stools
• Protein catbolism and ? BUN
• Acute hypovolemia ? renal hypoperfusion and
• ? excretion of urea ?
• ? BUN
• The patient does not have primary kidney disease
• No history
• Serum creatinine is normal at 1.1 mg/dL (0.7-1.4
  mg/dL reference range)

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Additional Studies
Coagulation
Electrolytes
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Vomiting

• Acid-losing alkalosis (Metabolic alkalosis)
• The gastric mucosa produces HCl by carbonic
  anhydrase mediated conversion of H2CO3 ? HCO3-
  and H
• Gastric HCl is lost in vomiting (the most common
  cause of metabolic alkalosis)
• H is continually being lost. H2CO3 is
  continually being consumed to replace H (and as
  a consequence, HCO3- ?)
• CO2 component ? because the HCO3- that is
  released when HCl is produced remains in the
  bloodstream and gets broken down to CO2 and
  water.
• Because H2CO3 is decreased, the lungs tend to
  retain CO2 to compensate generally not
  sufficient to prevent an increase in the usual
  201 ratio of HCO3- to H2CO3

? HCO3- excreted by kidneys over 3 4 days
H2CO3 H HCO3- CO2 H2O Lab
measures Carbonic Bicarbonate
HCO3- to acid ion
represent total CO2
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Clinical Course

• Patient immediately begun on IV fluids. Why?
• After blood typing and cross matching, he
  received three units of packed RBCs.
• He continued to bleed. Laparotomy and gastrotomy.
• Gastric lesion excised and blood clots removed.
• Post operative course was uneventful and patient
  was discharged two weeks later.

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Transfusion Guidelines for Acute Blood Loss

• Blood Loss gt 25 of total blood volume
• Transfusion is not ordinarily indicated for acute
  blood losses of lt25

• Give stored whole blood
• Blood volume expansion is gt the increase in Hgb
• 1 unit whole blood ?
• 10 expansion in blood volume
• 0.5 g/dL inc. in Hgb
• 1.5 inc. in Hct

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Transfusion Guidelines for Chronic Blood Loss

• Decompensated patient ONLY!!
• Transfusion is not indicated for a compensated
  patient with chronic blood loss

• Give Packed RBCs to provide minimal volume
  expansion
• 1 unit of packed RBCs ?
• 6 expansion in blood volume
• 1 g/dL inc. in Hgb
• 3 ? in hct

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Hematology
( )
( )
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Endoscopic View - Differential

• Gastric tumors - 2 to 4 per cent of upper GI
  bleeds
• Gastric lymphoma usually located in the corpus.
  Prognosis better.
• Helicobacter pylori has been associated to the
  development of mucosa-associated lymphoid tissue
  (MALT). Major role of H. pylori in the
  development of MALT lymphoma

BenignUlcer
GastricLymphoma
Gastriccarcinoma
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Peptic Ulcer
Eroded artery
Base ofUlcer
Base of Ulcer Rt. Side of image
Active granulation tissueproliferating small
blood vessels fibroblasts, Inflammatory cells
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H. Pylori and Peptic Ulcer Disease

• The gram-negative organism, H. pylori, was first
  linked to gastritis in 1983.
• Organism safely inhabits its host for years,
  producing mucosal inflammation
• Significant risk factor
• Prevelance
• Developing countries gt50 of population
• US - 5-10

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Peptic ulcer
Normalgastricmucosa
In addition to lymphocytes And plasma cells in
the lamina propria, neutrophils are visible
within the epithelium above the basement membrane
Gastric mucosa demonstrating S-shaped bacilli c/w
Helicobacter pylori
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Case Summary

• Final Diagnosis
• Peptic ulcer
• Helicobacter pylori infection
• Patient begun on therapy with H-2 receptor
  antagonists and antibiotics for H. pylori
  infection