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Abstract: A 40-year-old male patient with a history of surgical treatment for gastric cancer presented with nausea, vomiting, and subsequent vomiting of blood following gastric discomfort. Symptoms of hemorrhagic shock, such as blackness before the eyes and dizziness, were already present at the time of hospital visit. After timely treatment, the condition was stabilized, but then he vomited blood again. Considering the presence of active bleeding, gastroscopy was given and lesions were found in the gastroesophageal anastomosis, which was immediately treated with endoscopic electrocoagulation and titanium clips to stop bleeding, and the patient’s condition gradually recovered.
Basic information】Male, 40 years old
Type of disease】Hemorrhage, hemorrhagic shock, gastrointestinal bleeding, gastroesophageal anastomosis bleeding
Hospital】The Second Hospital of Harbin Medical University
Date of Consultation】March 2022
Treatment plan】Medication (saline + human albumin + injectable hemagglutinin + esomeprazole sodium + growth inhibitor + injectable terlipressin) + plasma + red blood cell suspension + endoscopic treatment (electrocoagulation hemostasis + titanium clip hemostasis)
[Treatment period] 15 days of inpatient treatment, 1 month of outpatient review
Treatment effect】No vomiting, no blood in stool, normal indexes
I. Initial consultation
A 40-year-old male patient presented with no obvious cause of epigastric fullness and distension, followed by nausea and vomiting, with early vomitus being stomach contents without blood-like material. The patient vomited more violently, and after 4 vomits, he vomited blood 3 times, fresh red, totaling about 1000 ml, containing blood clots, accompanied by black stools, unformed, with 2 discharges, amounting to about 200 ml. The patient then developed symptoms of pallor, cold sweat around the body, dizziness, weakness, and blackness in front of the eyes. The family urgently called 120 for emergency medical treatment. When we received the patient, we found that he was in extremely poor general condition, with a wet and cold perimeter, pale lips, blood pressure of 60/40 mmHg, heart rate of 128 beats/min, and pressure pain in the upper abdomen. He was diagnosed with gastric cancer six months ago and was treated with resection. The initial diagnosis was shock and gastrointestinal bleeding caused by excessive blood loss. Considering that the patient was in shock, he was immediately pushed into the resuscitation room, given treatment such as hemostasis, fluid replacement and pressure elevation, and improved laboratory tests such as blood routine, blood type, liver and kidney function, and coagulation function. Routine blood return: erythrocytes 1.91×10^12/L, hemoglobin 48g/L, renal function: urea nitrogen 11.55mmol/L, creatinine 132umol/L, liver function: alanine aminotransferase 47U/L, aspartate transferase 54 U/L, albumin 29.2g/L. Coagulation function was normal. The above results suggest that the patient is currently anemic and needs urgent blood transfusion treatment.
II. Treatment history
Considering that the cause of the patient’s shock was related to excessive blood loss, the body was in a hypovolemic state, which needed to be corrected rapidly, the patient was immediately given a rapid infusion of saline and human albumin for volume expansion and rehydration, emergency infusion of red blood cell suspension and plasma, and intravenous injection of hemagglutinin to stop bleeding. Therefore, the proton pump inhibitor esomeprazole sodium injection was given immediately to inhibit gastric acid secretion and protect the gastric mucosa, while growth inhibitor for injection and terlipressin for injection were used to reduce visceral blood flow and promote vasoconstriction to control bleeding. The patient’s condition was stable for a while, and the routine blood test was repeated: leukocytes 5.9×10^9/L, erythrocytes 2.57×10^12/L, hemoglobin 73 g/L. However, about 2 hours after the patient’s blood pressure stabilized, he vomited blood again with a bright red color and an amount of about 400 ml, and the patient was considered to have active gastrointestinal bleeding. After communicating with the family about the seriousness of the condition and the need for immediate gastroscopy and emergency endoscopic treatment if a lesion was found, the family agreed to sign after explaining the risks of the examination and treatment, and the gastroscopy unit was contacted urgently for further treatment.
Initially, after rapid expansion and rehydration, the patient’s blood pressure was still low, around 80/50mmHg. Considering that the patient was more anemic, he was immediately infused with red blood cell suspension. After giving the above treatment, the patient’s blood pressure was once gradually stabilized and could be maintained at around 100/90 mmHg, and the hemoglobin reached a relatively safe level after the transfusion. However, the patient had active bleeding again, and emergency blood transfusion was given again. At the same time, emergency endoscopy was given, and erosion of the gastroesophageal anastomosis was found, with jet-like bleeding at the erosion, which was immediately treated with microscopic electrocoagulation and titanium clips to stop the bleeding.
III. Treatment effect
After treatment, the patient did not have any more vomiting blood and blood in stool. After 10 days of hospitalization, the patient’s blood count was rechecked: leukocytes 6.9×10^9/L, red blood cells 2.44×10^12/L, hemoglobin 92g/L, renal and liver functions were basically normal, and coagulation function was normal. The patient was discharged, and was instructed to review the outpatient clinic after 1 month.
IV. Notes
The patient was discharged from the hospital in good health, and my family and I were very happy, but before discharge, we still advised the patient and his family to go to the hospital regularly for gastroscopy to observe the repair of the anastomotic lesion. Try to avoid non-steroidal drugs such as aspirin in medication. In addition, patients have titanium clips in their bodies, which usually fall off on their own in about half a month and are excreted with feces, so don’t worry. And it is recommended that the patient’s diet should be mainly liquid and light after discharge, pay attention to supplemental nutrients, avoid spicy and stimulating food, and try to control the action of increasing abdominal pressure such as coughing and defecation. Daily need to pay attention to the color of the stool, if there is a black stool, usually indicates a small amount of gastrointestinal bleeding may, do not panic, can go to the hospital to improve the fecal occult blood test, if positive, need to check the gastroscopy, observe the anastomotic lesions, adjust the medication. If the patient has coffee-colored vomit, excluding food or drug interference, it usually indicates the presence of gastrointestinal bleeding, and early hospital consultation is recommended.
V. Personal insight
In this case, the patient suffered from gastrointestinal bleeding due to lesions in the anastomosis after gastric cancer surgery, resulting in excessive blood loss and shock. Gastric resection is prone to anastomotic lesions such as inflammation, erosion and ulcer, which can easily cause gastrointestinal bleeding. If patients lose a lot of blood in a short time, it can cause hemorrhagic shock, which may be life-threatening if not treated timely. Therefore, for patients treated with gastric cancer surgery, the diet should pay attention to nutrition in order to promote anastomotic repair and regular gastroscopy to achieve early detection and early treatment of diseases to avoid life-threatening adverse events.