interesting case of gi bleed dr charles panackel md dm, dr sunil k mathai md, dm department of...
TRANSCRIPT
Interesting case of GI bleed
Dr Charles Panackel MD DM, Dr Sunil K Mathai MD, DMDepartment of Gastroenterology, Medical Trust Hospital, KochiPresenting Author – Dr Sunil K Mathai, HOD Gastroenterology
History
•56 year old female•Admitted with
▫Hematemesis - 2 episodes▫Malena - 3 episodes▫Generalized weakness▫Giddiness
Admitted to ICU
•Hemodynamically stable•PR – 80 / min., BP – 140/70 mm Hg•RT inserted – no fresh blood, coffee
ground aspirate•General examination – mild pallor +•Systemic examination – no s/o liver
disease▫No contributory findings
Urgent Endoscopy
Ulceration with Adherent Clot in Mid Esophagus
? Aortoesophageal fistula
Flash Back
Fish bone in mid esophagus in 2005. Active oozing ++ -Referred to MTH
Flash Back
•CT Chest- Fish bone in mid esophagus piercing aorta
•Emergency Thoracotomy with aortic repair on 21/03/2005
•Uneventful till date…. When she presented with GI bleed on 15/o6/2012
Back to case
CT chest with aortogram
Diagnosis
Upper GI BleedAortoesophageal Fistula
How to Manage ?
How to Manage ( what literature says?)• High mortality
•Common cause of death – ▫ Exsanguinating Bleed ▫ Infection
How to Manage ( what literature says?)•2 main options for Aortic Pseudo
aneurysm▫Open surgery
Aortic repair using – Synthetic material Pedicle graft
Thoracic esophagectomy + cervical esophagostomy + gastrostomy
▫Endovascular repair
How to Manage ( what literature says?)•Esophageal defect ??
• Leave it alone ??
• Esophagostomy/Esophagectomy ??
• Stenting ??
Plan •Endovascular repair
•Esophageal Stenting
•PEG for Feeding
•Antibiotics
Esophageal stenting done
PEG tube for feeding
Follow up aortogram
•Both stents well in situ
•No obvious leak seen.
•Antibiotics
•PEG feed
CT Chest after 2 weeks
Follow up
•Six weeks
•Patient eating well
•No infection or leak
•Planned for removal of esophageal stent
At Six weeks
•At six weeks
Granulation tissue in growth at both ends of esophageal stent. Unable to remove
APC done to ablate the granulation
Still stent could not be dislodged.
Six Months
•Both Stents in situ
•In growth of Granulation tissue at both ends. Planned for APC
Thank you.