Sunday, August 27, 2023

I think she may have given ME an ulcer!

At 5 years old, it was an unusual combination of symptoms. Fever, black stools and abdominal pain. Initial bloodwork showed a low blood level less than half of normal and malaria positive. Malaria explained the fever and low blood but the dark stools and abdominal pain were more of a mystery. Black stools are often a hallmark for bleeding. But malaria doesn’t cause bleeding… Bleeding AND malaria would be an unusual combination. 

I asked her if her tummy hurt and she indicated exactly where. After further assessment, she was subsequently taken to the operating room and found to have a 3cm hole in her stomach. This made sense as to the source of the bleeding. All else seemed normal. A straight forward repair was performed. Post-operatively she was put in the intensive care unit. She was a tough little girl and was not afraid to tell me when she didn’t want me examining her abdomen or wound. When I asked her questions she would reply with a silent but definitive nod or shake of her head.

When her bowels started to function several days after surgery, her black stools persisted. This seemed odd given the recent stomach repair. It would be unlikely for this to fail or bleed but not out of the realm of possibility. But she did have a lot of residual blood in her bowel seen at the time of the surgery. Perhaps this blood was still working its way out. 

Further blood work showed another significant drop in her blood level! 

This was NOT normal. She had to be still bleeding from somewhere. 

As a surgeon, if you do enough surgery, complications are inevitable but they are devastating in children and even more so with limited resources and ICU capacities. How could I have messed up that gastric repair I thought to myself. (actually it was my resident who did it… but I was supervising him) I have done many in my career. I teach them!… I explained the situation to her mother and suggested that if the dark stools didn’t stop, she would need another surgery. 

I was annoyed. We had just got her through this first surgery. 3 days of no eating,  an irritating tube in her nose, lots of IVs and needle pokes and not to mention trying to explain all this to a 5 year old. I dreaded the idea of having to operate on her again! 

Without pediatric endoscopic capacities, it is hard to evaluate the inside of the stomach and intestine. Not totally convinced the stomach repair was the problem, I used a brochoscope (normally used for lungs) to look into her stomach before committing her to another surgery. The stomach was clean. No blood! The repair was intact. No issues. Further down into the intestine (with some difficulty given the bronchoscope doesn’t navigate totally well in the stomach, I saw evidence of some ulceration but no active bleeding. This could explain the bleeding but she was already on anti-ulcer medications. I increased her dose and decided to continue to observe and transfused her again. The scope seemed reassuring.

Within an hour, a 30 year old lady arrived vomiting profuse amounts of fresh red blood. This year, we received from Samaritan’s Purse, an endoscopy set that allows us to do upper endoscopy in adults. We can put a camera in the mouth into the stomach and esophagus and place “elastic bands” around bleeding vessels called varices. People develop this bleeding due to a parasite which is endemic here called schistosomiasis. This is the only effective treatment here to treat bleeding esophageal varies. Prior to the arrival of this lifesaving equipment, patients would get transfused endlessly (or until they ran out of funds) with the hopes the bleeding would stop. Many people died. Blood transfusions are expensive and not often definitive. In fact, the cost of one transfusion is roughly the cost of doing this procedure so it is very much worthwhile for many reasons.

The young woman was very unstable having vomited perhaps 2L of fresh blood. Luckily we had a transfusion running. We intubated her to protect her airway. As I place the gastroscope down her esophagus, multiple juicy dilated veins were seen one of which was bleeding. 13 bands later the bleeding was stopped. I thought wow, that was a lot of blood. Surely this day couldn’t get anymore red. I left the OR staff to clean up and went to check on the little girl from earlier.

To my horror, the little girl was laying in her bed surrounded in fresh blood and vomitting more. I said to myself what is going on today with blood and vomit?…. Given her weight, she had an estimated total blood volume in her body of 800mL and there was probably close to that much on her bed with more coming. We quickly worked to stabilize her. She needed an operation emergently. If she was bleeding this much and this fast, not even transfusing her as fast as we could would save her.

Where was all this blood coming from when I just seen the stomach clean not 3 hours earlier!

She was taken to the operating room and surgery revealed lots of clot in her bowels. Her previous stomach repair was intact. Finding bleeding outside the bowels is easy. Finding it on the inside is more challenging because it is like looking for a bleed inside a pipe that you can’t see in! An adult bag of blood was hanging. 

We needed to get this sorted out or she was going to die. 

Using our donated Thompson abdominal retractor (thank you Thompson for this awesome tool!) I opened the duodenum deep inside the abdomen where I had seen evidence of an ulcer on the scope. To my shock, it was clean inside. There was no blood. 

What is going on I asked my resident? 

We looked distally and saw no blood and then looked proximal in our opening. A large ulcer with a tenuously clotted blood vessel in the center was just up from where we had made our incision. My resident dabbed it with a compress and then the arterial hose unleashed itself. "I think you found it," I told him. In a matter of seconds, the bowel was rapidly filling with blood. 3 strategically placed sutures later and the bleeding was stopped. The large ulcer had eroded into a blood vessel and given its location, it could not be seen during the first operation. This vessel is known to cause catastrophic bleeding when ulcers occur exactly over it.

Several days later in the ICU, her stools normalized and her pain subsided and her blood level didn’t drop any further. She received more than her entire blood volume in transfusions during her hospital stay. Her mom asked if she could eat chicken. I said yes. Looking at the girl she may have cracked a smile when I told her if she was going to eat chicken she might need to give me some:-)!

Both the girl and the other lady from that day are alive and well...Hurray! 

Huge thanks to our lab staff who work tireless finding donors and blood so that we can save kids and people like this. We have no blood bank. All our transfusions come from live donors!

Today the little girl was discharged from hosptial! 

I was also extremely happy though I think she may have given me an ulcer... JESH

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I think she may have given ME an ulcer!

At 5 years old, it was an unusual combination of symptoms. Fever, black stools and abdominal pain. Initial bloodwork showed a low blood leve...

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