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A Case of the Week

Case 54

 An eighty two-year-old female had been admitted in the local hospital for influenza and Parkinson disease for previous several days. She experienced tarry stool four times in the morning. Because laboratory test revealed hemoglobin (Hb) of 5.7 g/dL, she was transported to our hospital. Her conjunctiva palpebra (eyelid) showed anemia. Laboratory test in our hospital revealed red blood cells 1.86 million/mm3, Hb 5.8 g/dL, hematocit 18 %, CRP 9.15 mg/dL, PTINR 1.37, fibrinogen 522 (170 – 400) mg/dL, platelets 220 (10-3μ). She received non-enhanced CT and endoscopy.
 Day 1, non-enhanced CT showed slight high density mass between pancreas and liver, indicating hematoma (Fig. 1). Endoscopy revealed the arterial bleeding from duodenal ulcer and successful hemostasis was achieved (Fig. 2).
 Day 2, the follow-up endoscopy revealed oozing and the arterial bleeding recurred. The re-hemostasis was achieved again (Fig. 3), but the endoscopy physicians asked us to occlude the bleeding site using interventional procedure because they considered the hemostasis potency by endoscopy was not durable.
 Then, angiography was attempted for transcatheter arterial embolization.

What is the most appropriate management for gastroduodenal bleeding with coagulopathic condition ?

a. Embolization with gelatin sponge particles

b. Embolization with n-butyl cyanoacrylate

c. Embolization with microcoils

d. Surgical repair

1.a, b, c   2. b, c   3. a, c    4. d


2017.5.17



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