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A difficult case of gastrointestinal haemorrhage
  1. I S Shawa,
  2. S D Hearingb,
  3. M Callawayc,
  4. C S J Probertb
  1. aBristol Royal Infirmary, Bristol, UK: Department of Gastroenterology, bUniversity Division of Medicine, cDepartment of Radiology
  1. Dr Christopher S J Probert, University Division of Medicine, Bristol Royal Infirmary, Bristol, BS2 8HW, UKc.s.j.probert{at}bristol.ac.uk

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Answers on p 414.

A 64 year old man presented to the accident and emergency department, having been found collapsed in the street. He gave a four day history of melaena. On examination he was shocked, with a pulse of 140 beats/min and a blood pressure of 70/40 mm Hg. Initial haematological assessment revealed a haemoglobin concentration of 65 g/l, platelet count 68 × 109/l, and international normalised ratio 1.3. After resuscitation with intravenous colloid fluids, blood, fresh frozen plasma and platelets, an emergency upper gastrointestinal endoscopy was performed. This showed four large oesophageal varices, two of which were actively bleeding. Endoscopic sclerotherapy was attempted, but haemostasis was not achieved, and a Sengstaken tube was sited.

The next day the Sengstaken tube was removed and endoscopic band ligation of the oesophageal varices performed. The patient remained stable for 24 hours until there was evidence of further gastrointestinal bleeding, with passage of melaena, and haemodynamic compromise. A further upper gastrointestinal endoscopy was performed, which revealed a large quantity of blood in the stomach; the oesophagus was well visualised and confirmed not to be bleeding. A therapeutic procedure was performed (fig 1).

Figure 1

Therapeutic procedure performed on patient.

The procedure successfully stopped further gastrointestinal haemorrhage. However, two days later, he became drowsy and disorientated.

Questions

(1)
Following the insertion of the Sengstaken tube what additional management would you have instigated?
(2)
What was the cause of the rebleed and what procedure was performed?
(3)
What is the likely cause for the patient becoming drowsy, and how would you manage this?

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