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Abstract: The patient in this case is a 68-year-old grandfather with a history of chronic hepatitis B for more than 40 years, diagnosed with cirrhosis in the decompensated stage 8 years ago, who usually adheres to oral entecavir tablets and Anluo Fibrillation Pills for antiviral and antifibrotic effects. On the day of admission, upper gastrointestinal bleeding and hemorrhagic shock occurred due to improper diet, and the patient’s condition was stabilized without further gastrointestinal bleeding after aggressive comprehensive treatment of fluid replacement, hemostasis, and prevention of rebleeding.
Basic information】Male, 68 years old
Type of disease] Upper gastrointestinal bleeding
Hospital】The 988th Hospital of the PLA Joint Logistics and Security Forces
Time of consultation】December 2021
Treatment plan】Medication (octreotide acetate injection, pantoprazole sodium for injection, magnesium isoglycyrrhizate injection, glutathione for injection, spironolactone tablets, furosemide tablets, cefoperazone sodium sulbactam sodium for injection) + surgical treatment (esophageal variceal ligation treatment)
[Treatment period] 4 weeks of hospitalization, review every 3 months, long-term home treatment
Treatment effect】The condition gradually stabilized, the indicators recovered, and the clinical symptoms reduced
I. Initial consultation
The patient was admitted to the hospital in an emergency, in a state of shock, with a somewhat blurred state of consciousness, pale face, slightly closed eyes, responsive to calls, dry and cold limbs, a bulging abdomen with a frog’s belly, and multiple spider nevi scattered on the forehead and neck. The patient’s medical history was briefly asked: 8 years of cirrhosis, 3 years of hypertension, repeated occurrences of ascites, hepatic encephalopathy, gastrointestinal bleeding, a little shredded pork with celery at about 20:00 tonight, and suddenly fainted when going to the toilet at 23:00 and was rushed to our hospital. The chief of neurology checked the patient and said: Although the patient had a history of hypertension, the current blood pressure was 80/55 mmHg, there were no positive neurological signs, and stroke was temporarily excluded. The ICU doctor and I considered gastrointestinal bleeding and hepatic encephalopathy, but preferred gastrointestinal bleeding, but it was not good to jump to a conclusion without blood vomiting or blood in stool, so we had to rehydrate first. 1500ml, the patient’s blood pressure quickly dropped to 70/40mmHg, and then fainted again. Accordingly, the upper gastrointestinal bleeding due to rupture of cirrhosis combined with esophageal varices was established, and the patient was immediately transferred to ICU for hemostatic treatment under close supervision.
II. Treatment history
After admission to ICU, the patient was given octreotide acetate injection, sodium pantoprazole for injection, blood transfusion, etc. After 5 days, the stool turned yellow and the hemoglobin rose to 98g/L. There was no further active bleeding, but the ascites increased and the bilirubin rose, requiring further hepatoprotective and diuretic treatment, and was transferred to our department. After admission, he was given magnesium isoglycyrrhizate injection and injectable glutathione to control hepatocyte inflammation and lower bilirubin, and spironolactone tablets and furosemide tablets for oral diuresis. On examination: the patient had chronic pressure pain and rebound pain in the abdomen, and the cell count in ascites was significantly elevated. considering the combination of peritonitis after gastrointestinal bleeding, anti-infection treatment with injectable cefoperazone sodium sulbactam was added. around 10 days, the patient’s liver function gradually improved, bilirubin decreased, ascites basically subsided, and peritonitis was controlled. After applying for gastroscopy, severe varices of esophageal veins were seen under endoscopy, and esophageal variceal ligation treatment was performed after communicating with the family.
III. Treatment effect
The patient was admitted to the hospital after three stages of treatment, namely, 1) resuscitation of upper gastrointestinal bleeding and shock; 2) liver preservation and management of complications; 3) pretreatment of rebleeding, and the patient finally turned to safety. After treatment, liver function was basically normalized, only albumin was low, bilirubin and transaminases were normal, ascites disappeared, peritonitis was controlled, and the key was the treatment of esophageal variceal ligation, which has a better effect on preventing rebleeding in patients with cirrhosis, but is not a once-and-for-all treatment plan. After all, cirrhosis still exists, and poor blood flow from the portal vein to the liver can still lead to increased pressure in the collateral circulation, and the esophageal and fundic veins have food friction every day, which is one of the branches most prone to bleeding.
IV. Notes
I am very glad that the patient has turned to safety after treatment, but after discharge from the hospital, it is necessary to continue treatment and regular checkups, and any uncomfortable symptoms should be seen in the hospital immediately to avoid delaying the disease.
1, pay attention to rest, avoid exertion, staying up late, getting cold, large mood swings, abstain from smoking, alcohol, strong coffee, strong tea.
2.Forbid to eat raw, cold, hard and spicy stimulating food, eat less and more meals, avoid eating too cold, too hot, too hard, too full, so as not to damage the esophagus, gastric mucosa, blood vessels and induce rebleeding.
3.If you have cold, fever, joint pain, etc. in daily life, try to avoid using NSAIDs to prevent such drugs from damaging the gastric mucosa and inducing gastrointestinal bleeding.
4, usually pay attention to observe the color of the stool, if you find black stool, or acid reflux, heartburn, bloating and other uncomfortable symptoms, promptly go to the hospital for medical consultation.
5. It is recommended to review the gastroscopy once every 6-12 months to assess the condition.
V. Personal insight
The four common causes of upper gastrointestinal bleeding are peptic ulcer, rupture of esophagogastric fundic varices in cirrhosis, acute erosive hemorrhagic gastritis, and gastric cancer, as well as many other causes of bleeding of different degrees. Once bleeding occurs, it will cause strong fear of patients and family members, and if the medical treatment is not timely, it may also endanger the life. Therefore, the daily diet should be regular, medical checkup should be conducted every 1-2 years if possible, and timely medical treatment and near medical treatment should be provided for the occurrence of gastrointestinal bleeding to avoid delaying the disease.