Upper digestive bleeding due to Dieulafoy's lesion during the postoperative period of aortocoronary bypass surgery in a patient treated with clopidogrel

Abstract

Gastrointestinal complications of cardiac surgery are infre-quent (0.3-3%) (1-3), but condition the prognosis of the patient. Upper digestive bleeding (UDB) is the most frequent complica-tion of this kind. UDB is regarded as the expression of diffuse aggression on the body in the context of a risk situation, repre-senting 28-31% of all gastrointestinal complications (4). In this setting, ulceration is the most common manifestation. The un-derlying etiopathogenesis would involve splanchnic hypoperfu-sion produced by the release of endotoxins, with immune alter-ations of the gastric mucosa and an increased risk of bacterial translocation (5). We present the case of a patient with UDB in the postoperative period of aortocoronary bypass surgery. Clinical case A 65-year-old male reported to the emergency service with hematemesis and melena. The personal history revealed is-chemic heart disease with coronary revascularization and dou-ble bypass surgery without the use of an extracorporeal circuit (ECC) performed 10 days before in another center; dyspepsia not subjected to evaluation; arterial hypertension; dyslipidemia; and type 2 diabetes. The patient was being treated with clopido-grel, candesartan, hydrochlorothiazide, diltiazem, simvastatin, pentoxifylline, cinitapride and insulin. The physical examina-tion revealed hypotension (70/50 mmHg), heart rate 110 bpm, and pale skin and mucosal membranes. The rest of the findings were normal. Blood testing in turn showed hematocrit 26.7%, hemoglobin 9.2 g/dl, MCV 84 fl, urea 18 mmol/l, platelet count 579,000, with normal values for aPTT and prothrombin time. Severe (9 points of the Rockall scale) UDB was thus diag-nosed. Treatment was started with the water and electrolyte re-placement and intravenous pantoprazole. Gastroscopy in turn revealed a 3-4 mm aberrant vessel with jet-like bleeding (For-rest 1a): 10 ml of adrenalin (1/10,000) and 3 ml of 1% polydo-canol were injected, after which the bleeding subsided. Two hours later the patient developed another episode of hemateme-sis with hypotension (70/45 mmHg); as a result, endoscopy was Fig. 1. Aberrant vessel with jet-like bleeding (Forrest 1a).