Interesting case of GI bleed Dr Charles Panackel MD DM, Dr Sunil K Mathai MD, DM Department of...
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![Page 1: Interesting case of GI bleed Dr Charles Panackel MD DM, Dr Sunil K Mathai MD, DM Department of Gastroenterology, Medical Trust Hospital, Kochi Presenting.](https://reader036.fdocuments.us/reader036/viewer/2022062409/5697c0051a28abf838cc4d5e/html5/thumbnails/1.jpg)
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
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History
•56 year old female•Admitted with
▫Hematemesis - 2 episodes▫Malena - 3 episodes▫Generalized weakness▫Giddiness
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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
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Urgent Endoscopy
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Ulceration with Adherent Clot in Mid Esophagus
? Aortoesophageal fistula
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Flash Back
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Fish bone in mid esophagus in 2005. Active oozing ++ -Referred to MTH
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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
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Back to case
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CT chest with aortogram
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Diagnosis
Upper GI BleedAortoesophageal Fistula
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How to Manage ?
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How to Manage ( what literature says?)• High mortality
•Common cause of death – ▫ Exsanguinating Bleed ▫ Infection
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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
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How to Manage ( what literature says?)•Esophageal defect ??
• Leave it alone ??
• Esophagostomy/Esophagectomy ??
• Stenting ??
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Plan •Endovascular repair
•Esophageal Stenting
•PEG for Feeding
•Antibiotics
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Esophageal stenting done
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PEG tube for feeding
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Follow up aortogram
•Both stents well in situ
•No obvious leak seen.
•Antibiotics
•PEG feed
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CT Chest after 2 weeks
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Follow up
•Six weeks
•Patient eating well
•No infection or leak
•Planned for removal of esophageal stent
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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.
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Six Months
•Both Stents in situ
•In growth of Granulation tissue at both ends. Planned for APC
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Thank you.