Acute gastrointestinal bleeding from a chronic cause: a teaching case report

Abstract

Gastrointestinal bleeding (GI bleed) is a common and potentially life-threatening reason for emergency room and intensive care unit admission. This article reports the case of an 83-year-old man with acute GI bleeding from an unusual cause. The clinical information is presented in a step-by-step and question-answer format for learning purposes. This paper is particularly aimed at an internal medicine readership. Case presentation In March 2011, an 83-year-old man developed paroxys-mal atrial fibrillation and distal right leg ischaemia successfully treated with embolectomy. He had a remote medical history of hypersensitivity pneumonitis (from mushroom farming), coronary artery bypass grafting (CABG) surgery, chronic lymphocytic leukaemia (CLL), and Billroth type II gastrectomy for previous gastric ulcer bleeding. His medication included a β-blocker, a statin, low-dose aspirin, an angiotensin II receptor blocker and a proton-pump inhibitor (PPI). Lab results were normal except for slight thrombocyto-penia (141,000 platelets/µL; normal range 150,000-450,000 platelets/µL) and lymphocytosis (21,675 cells/µL, normal range 1,200-3,600 cells/µL with smudge cells, monoclonal B-lymphocytes 17,700 cells/µL). Echocardiography showed only left atrial dilatation and grade 2 mitral insufficiency, without inferior vena cava dilatation. He lived independently and was in an excellent general condition, going on regular skiing holidays. Question set 1 1. Which risk factors for bleeding does this patient have? 2. Which anticoagulation strategy would you rec-ommend?