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Life is never easy


Life is never easy


حالة سريرية

الوصف الكامل Background
Here is a case for discussion. This is not a cse taken from exams books or a case that I made up from my mind to fit a certain diagnosis. This a true life case that I am still suffering with.

A 41 y old female presented to neurology with loss of consiousness (LOC) and ? seizure activity : after neuro work up including MRI brain she was found to has only Hb 4.9 with everything else normal. She did mention vomiting after she woke up from the attack of LOC associated with mild epigastric pain . That lasted for few minutes and then resolved.
She denies black tarry stool, hematochezia , hematemisis, heartburn, change in bowel habits, weight changes or any other symptoms except fatigue and dizziness.No previous medical problem , No surgeries, No smoking or alcohol . No medications either. She works as a maid
Her exam is remarkable for pallor but otherwise normal. By the time I saw her she was already transfused 2 units of blood and her Hb was up to 8. She was already tested for Iron indeces that showed significant Fe deficiency (Fe sat % was 5% - normal 20-30%)
SO what is the next step?

ABIM's picture
by


بعمل لطاخة دم محيطية .
EGD & COLONOSCOPY

drhanadi's picture
drhanadi
طبيب مقيم


By the way there is no vaginal bleed . the woman is not pregnant she 2 children 2 and 6 years. Her period is normal.
The CBC shows low MCV, high RDW.
You want to look at the peripheral smear : you can but is there anything other than Fe deficiency you want to look at there?
THe other question: Do you want to do both EGD and colonscopy or do want to start with one and then do the other if the first is normal. Remember she is a maid. We want to minimize tests and proceudres to minimize the cost and avoid any unnecesseray tests

ABIM's picture
ABIM


أنا فكرت بلطاخة دم محيطية من الممكن كشف أسباب دموية لفقر الدم Rolling Eyes
أنا فكرت ابدأ بالتنظير الهضمي العلوي واطلب تحري دم خفي ...لاحقا فكرت انه اذا طلع تحري الدم الخفي ايجابي رح نعمل تنظير واذا طلع سلبي فسلبيته ما بتنفي ورح نرجع نعمل تنظير .
بظن انه أولا EGD واذا طلع ايجابي منعالج السبب وبقي فقر الدم موجود مننتقل لتنظير الكولون واذا طلع سلبي مننتقل فورا لتنظير الكولون .

drhanadi's picture
drhanadi
طبيب مقيم


occult blood in stool was positive
EGD : Esophagus was normal
Gastric (stomach was normal
Doudenum : fisrt ,second and third portions were normal.

The patient was prepared for colonoscopy at the same session to be done if needed.
As endoscopists we some times try to go deeper in the small intestines with the upper scope . It is not always technically possible but in this case I passed the scope into the forth portion of the duodenum and on entering the jejunum there was a bulging mass on the side of the lumen with a small ulcer in the center. What would you do next?

ABIM's picture
ABIM


قد يكون فقر الدم من منشأ كلوي
لماذا لانطلب الكرياتينين أو تصفية الكرياتنين creatinine clearanc والذي يعتبر اختبار بيسط قبل طلب التنظير العلوي؟

Dr.M-S's picture
Dr.M-S
السنة السادسة

Quote:
قد يكون فقر الدم من منشأ كلوي
لماذا لانطلب الكرياتينين أو تصفية الكرياتنين creatinine clearanc والذي يعتبر اختبار بيسط قبل طلب التنظير العلوي؟

Emmm...Ok . I did mention that the anemia is microcytic with decreased Fe deficiency. So even if there is chronic renal failure that will NOT explain the anemia. I suggest to review the causes of Fe deficiecny anemia

We did move into the step of upper endoscopy and as I already said there was a large bulging mass with small ulcer and the next question was ? What to so next

ABIM's picture
ABIM


أكيد خزعة ومنبعتها للتشريح المرضي .

drhanadi's picture
drhanadi
طبيب مقيم

Quote:
أكيد خزعة ومنبعتها للتشريح المرضي

I agree, But anyone have different opinion?

ABIM's picture
ABIM


Ok . I started to take biopsies and on the first punch biospy patient started to bleed so massively that no one could see anything but blood. WHen I injected epinephrine next to the bleeding site blood started to spurt from the small hole of the injection site. Patient was sedated at that time. Her BP started to drop and develop hypoxia and tachycardia...
What to do next?

ABIM's picture
ABIM

firsy stabilize the pt

and if we need the biposy to diagnose we need to solve the bleeding problem

as far as i understood this pt has
.LOC
.GI mass
.Iron deficiency anemia
.bleeding disorder

we can link IDA with the GI blood loss confirmed by +ve occult blood stool
and LOC with decreased brain perfusion since she regained it after blood transfusion

but what can make a pt bleed massively while taking a biopsy ?

maybe the problem in the liver ( clotting factors ) , bone marrow ( platelets ) ?

what other tests did u run on the pt other than Hb and Iron ?

امرأة لا تتكرر's picture
امرأة لا تتكرر
السنة الخامسة

Quote:
stabilize the pt

Yes indeed ..although easier said than done..
In 20 minutes patient had 3 IV lines all wide open ..blood requested from the blood bank (type O +) and patient was intubated. She was transferred to ICU after around 45 mintes.
BP was lowest 65 systolic transiently but with volume expansion and pressors (norepinephrine) it was brought up to 100. Her oxygenation was good and she started to wake up from sedation and had to be sedated again while kept on mechanical ventilation. One hour and a half later ... patient arrested: went to asystole.
COde blue was initiated and she was brought back after 7 minutes...
As for the coagulation profile it was not usually done before endoscopy . Only platlets were done and were normal.
But later PT and PTT (after arrest were mildly elevated)
By that time patient have received 2 unita of blood and at least 2 liter of fluids (and volume expansion) + FFP's.
SO what to do next? the bleeding is so massive?

ABIM's picture
ABIM

search for the cause of bleeding ?

and keep the fluid replacement therapy going on till diagnosis is established and treatment is given

امرأة لا تتكرر's picture
امرأة لا تتكرر
السنة الخامسة

this is a nice pdf about management of massive bleeding and coagulopathy
امرأة لا تتكرر's picture
امرأة لا تتكرر
السنة الخامسة

Quote:
search for the cause of bleeding ?

We already found the cause of bleeding . It is a large tumor in the beginning of the jejunum that started to bleed so massively on the first attempt to take biopsy. The question is what can we do now after the above described senrio in the ICU ...

ABIM's picture
ABIM


منعمل وظائف الكبد LFT؟
منعاير وظائف الكلية ؟
ممكن يكون عوز فيتامين K نتيجة سوء الامتصاص الحاصل كنتيجة لانسداد أو تحت انسداد بكتلة الورم ...
هذا ما فكرت به !

drhanadi's picture
drhanadi
طبيب مقيم


oh i thought she had a bleeding disorder and an episode was triggered by the stress she was subjected to and u couldnt approach the mass bcuz she bleeded while u started
so the bleeding is from the tumor
so its a stromal jejeunal tumor ?

a GI stromal jejunal tumor can cause massive bleeding and can b diagnosed and controlled by electrocoagulation by using double-balloon enteroscopy

امرأة لا تتكرر's picture
امرأة لا تتكرر
السنة الخامسة

Quote:
منعمل وظائف الكبد LFT؟
منعاير وظائف الكلية ؟
ممكن يكون عوز فيتامين K نتيجة سوء الامتصاص الحاصل كنتيجة لانسداد أو تحت انسداد بكتلة الورم ...
هذا ما فكرت به !

» نسخة للطباعة

Let me bring you the picture again..
The patient just coded and arrested . She was brought back with reasonable blod pressure. She is intubated getting all sorts of fluids, blood, FFP and STILL bleeding what is next?

ABIM's picture
ABIM

Quote:

oh i thought she had a bleeding disorder and an episode was triggered by the stress she was subjected to and u couldnt approach the mass bcuz she bleeded while u started
so the bleeding is from the tumor
so its a stromal jejeunal tumor ?

a GI stromal jejunal tumor can cause massive bleeding and can b diagnosed and controlled by electrocoagulation by using double-balloon enteroscopy

Right now we need action: patient continues to bleed.
You said electrocautery with double baloon enteroscopy. I appreciate the effort and the search you did to come up with very reasobale answer.
But remeber I had a scope already in the patient at the time of bleeding and I could not see a single thing but blood. Even when I tried to inject epinephrine next to the bleeding site to promote vasoconstriction and reduce the bleed so I can see and intervene blood started to come out from the small site of needle injection spurting out. It was very clear that I was dealing with heavily vascularized lesion and touching it any more is just waste of time and may be even more dangerous.
One idea about electrocautery: Although this is a perfect option for bleeding ulcers it s not expected to achieve much in deeply situataed tumors / abnormal tissue to support and allow meaningful effects of the tissue damage caused by electrocautery ( cauterization of tissue and creation of surrounding edema)

As for the second though of GI stromal tumor... I am impressed but what are you going to do about it

ABIM's picture
ABIM


i think why she bleeded when u injected beside the tumor is bcuz the primary GIST is often large, usually with an exophytic growth pattern (tumor grows between the bowel loops) and sometimes within the bowel lumen

Most metastases arise in the liver and peritoneal cavity, resulting from hematogenous spread (liver) and tumor peritoneal seeding for peritoneal metastasis

so why not try a liver CT?

--------

if its GIST then Surgical resection is the first-line intervention for operable GISTs, particularly localized primary tumors, and it was historically the only effective treatment.

if its unresectable or metastatic GIST then Imatinib is a potent, specific inhibitor of KIT inducing tumor shrinkage of 50% or more or stabilizing disease in most patients

امرأة لا تتكرر's picture
امرأة لا تتكرر
السنة الخامسة


أنا فكرت انه سبب النزف هو اعتلال دموي وليس الورم بحد ذاته .
بالنسبة لأورام الأمعاء الدقيقة بصراحة ولا بعرف شي عنها !!Shocked بعرف انها rare .
من خلال البحث على الانترنت ممكن نعمل MDCT للمريضة ما بعرف اذا موجود وممكن نستعمله كون المريضة غير مستقرة .
ولكن من خلاله ممكن نشوف اللمعة ، الجدار ، المساريقا ، والأوعية وبالتالي ممكن نعرف توعية الورم وكيف بدنا نوقف النزف بمعرفة أي وعاء ممكن نتداخل عليه .
وبظن ممكن بحالة نزف شديد نعمل laparoscopy ؟ ومنترك الموضوع للجراح ومنرتاحEmbarrased

drhanadi's picture
drhanadi
طبيب مقيم

The option was either
1- angiography with embolzation of the bleeding artery : and I was infavor of this option initially before the patient arrested
2- Surgical evaluation and resection

But after the patient arrested and efforts were successful to bring her back she was shifted right away to OR and laparotomy was done with removal of 9 cm mass in the beginning of the jejunum.
There is no room to talk about chemotherapy will the patient is actively bleeding like this. The main aim was to control and stop the bleed .
rigt away.
The pathology came back as GI stromal tumor indeed.
The massive bleeding was related to the nature of the dense vascularity of the tumor (which I have never seen like befor) and although this is described in the literature but never to this degree (hypotenion in minutes , arrest in 2 hours despite VERY aggressive fluid resusitation

The problem now is : she did not recover mentally ? still unresponsive 3 days post surgery desite no blled and not tumor
So what do you think ?medically and eithically

ABIM's picture
ABIM

الحمد لله ع السلامة .. أخيرا
i thought about this pt many times during day ,
very nice case dr.ABIM ,u really stimulate us to search and read
Quote:
ethically

i prefer to listen than to talk when it comes to ethics
anyway , am glad she's alive , thats all
she's lucky to have had an excellent doctor

امرأة لا تتكرر's picture
امرأة لا تتكرر
السنة الخامسة

الحمد لله ع السلامة .. أخيرا
i thought about this pt many times during day ,
very nice case dr.ABIM ,u really stimulate us to search and read
صحيح الحالة كتير حلوة ومبارح طول الليل وأنا فكر فيها حتى شفتها بمنامي كنت معها واقفة عم فكر شو اعمل Shocked
بظن انه طبيا وأخلاقيا الدكتور قام بواجبه على أتم وجه وما كان من الممكن تجنب الاختلاط الطبي الذي حدث .
i prefer to listen than to talk when it comes to ethics
anyway , am glad she's alive , thats all
drhanadi's picture
drhanadi
طبيب مقيم

I know the patient survived. I know that in 4 hours she had
1- 2 liters of fluids
2- 6 units of blood
3- 6 units of fresh frozen plasma
4- Intubation and mechanical ventilation
5- Open laparotomy with tumor resection

But you look at her she only blinks her eyes with minimal movements in her upper extremities and no other meaningful response. SHe does not talk and does not react .
I know that she had a very rare disease with extremely rare presentation and I would not have done anything different had it been possible to go back in time. I would have done the same biopsies and got into the same trouble. Despite all that I feel guilty and upset that the outcome still limited and not good enough. I do hope that she recovers more with time but I don't know if she will be able to hug her two children and play with them. I don''t know how she is going to pay for all the expenses of her treatment that is more than 50 times her monthly salary. ...
SOmetimes as physcians we will be faced with such senarios ,no matter what you do there is a limit to what you can offer. Sadly even if you go by the book and do everything to the best standerd you can never guarantee and result. I always try to remember that and try to ask Allah to cure my patients , I am just a human being...

ABIM's picture
ABIM

If i were you, i would not feel any guilt, you did nothing wrong or even short, i face procedure and treatment complications everyday, and believe me in our hospital she would have never made it to the OR, she would never have lived longer than the 7 minutes of resusitation.
just 2 days ago we were dealing with multiple organ failure case:
hepatic failure, renal failure, rash, seizures, respiratory distress followed by full cardiopulmonary arrest"...
the 18 years old female "solo child" was on 4 drugs TB regimen for 2 months, the nephrologist threw her on the GI specialist, and he in turn threw her to the pulmonologist who left her to the internist, who never showed up "because it was thursday night", i believe complications are not uncommon in daily practice after all.. one should only deal with the case and treat with the standerd of care "i believe you did even more than that", and hope to God the healer to help the patient, we provide medicine, and God provides the cure.. not us.

best wishes.

by the way ... our patient is still alive too... thank God.

dr.tabban's picture
dr.tabban

a very sad case
but you did what you could and tried your best
so I don't think You should feel guilty
it reminded my of this

:
فان الطبيب له علم يدل به ****** ان كان للمرء في الايام تاخير
حتى اذا ما انتهت ايام رحلته **** حار الطبيب و خانته العقاقير

a question:
Quote:
went to asystole.
COde blue was initiated and she was brought back after 7 minutes...

she has a brain injury because of the hypoxia

?

.b's picture
.b
بعد التخرج

Quote:
she has a brain injury because of the hypoxia[/quote
That's what looks like
ABIM's picture
ABIM


After less than 3 months the story came to an end today. The patient died today at another hospital. I feel quite confused about that.I don't know may be it is better for her to die than to live in the state where she is bedridden with no communication or expression of emotions. May be it will make it easier for the family to get over it or may be I can stop thinking that I had something to do with it.
I am quite helpless. one another feeling I can't run away from is how will the family think of me? Will they understand that I meant only good? will they know that what happened was unavoidable? Are they going to spare me or spare my family and hard wishes ? Or will anyone think that they should file a complaint against me and sue me for the damage and loss of life???
This is the way how life is : Good intentions and even good training can never guarantee good results. May Allah help us to be a tool for cure .........

ABIM's picture
ABIM

Quote:
This is the way how life is : Good intentions and even good training can never guarantee good results. May Allah help us to be a tool for cure

لا دكتور
النوايا الحسنة تضمن النتائج الحسنة في النهاية.
لأنك تتعامل مع الله و هدفك الله وليس المريض أو أهله.

.b's picture
.b
بعد التخرج


after reading the above:

firstly, it was really motivating
it was a good case
the strategy of dx was near perfect, but as u said dr there was sth unavoidable

i understand ur fellings doctor. it's really hard to face such things esp if u still have feelings. it's nt ur fault anyway, it's just her luck to get the endoscopy by a smart physician who wants 2 reach as far as possible
the title of the thread really mean it "Life is never easy"

Thanks 4 ur efforts with the pt and thank u more 4 the fine feelings u had 2 her after she was done....
May Allah help us to be a tool for cure and not for death

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Ghufran
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