Case Presentation

Hematemesis
Charlotte MN
Eka Satya Nugraha
Florence Low
Maria Rossyani Ekindriaty
Mikhael Yosia
Radhian Amandito
Vania Roswenda
Vika Ardianto Laksono

Patients Identity

Name
: Mr. SS
Date of Birth
: 21 October 1975
Age
: 33 years old
Gender
: Male
Religion
: Islam
Education
: Senior High School
Occupation
: Labour worker
Marital Status
: Married
Address
: Menteng
Date of Admission
: 8th January 2015 to ER, 12th
January 2015 to
the 7th Floor Ward.
Date of Examination
: 12th January 2015
Medical Record : 309-94-47

Anamnesis
Anamnesis
Autoanamnesis on 12th January 2015

Chief Complaint
Patient came with chief complaint of
bloody vomit since 12 hours prior to
hospital admission

Anamnesis

Physical Examination
Consciousness
General Condition
Vital Signs
Blood Pressure
Heart Rate
Respiratory Rate
Temperature
Anthropometry
Body Height
Body Weight
BMI

Physical Examination
Head
Hair
Skin
Eye
Ear
Nose
Mouth
Neck

Physical Examination
Lung
Inspection
Percussion
Palpation
Auscultation
Heart
Inspection
Palpation
Percussion
Auscultation

Physical Examination
Abdomen
Inspection
Percussion
Palpation
Auscultation
Extremities

Supporting Examination
Refe
Examination

Hematology
Hb

8/1/

renc

201

Valu

Unit

10.4 12.0 g/dL

-

Ht

15.0
31.6 36.0 %
-

Leukocyte

46.0
8,77 5-10 100

Thrombocyte

0
210

0/uL
150- 100

68

400
80-

22

95
27.0 pg

MCV/VER
MCH/HER

0/uL
fL

MCHC/KHER

33

31.0
32.0 g/dL

Resume
39 years old male patient came with chief
complaint of bloody vomit since 12 hours prior to
hospital admission.
The patient complains of hematemesis melena. He
had also suffered from similar complaint 3 months
ago with history of jaundice. Patient had
undergone 3 ligation procedures.
Physical examinations reveals that he had anemic
conjunctiva, icteric sclera and distended abdomen.
Laboratory examination shows that the patient had
anemia. EGD examination reveals that the patient
had: Varices esophagus gr II, mild gastropathy
hypertension portal. Ligation of varises is done in
3, 6, 9 and 12 oclock.

List of Problems

Esophageal varices gr II pro ligation

Liver cirrhosis
DM type 2
Anemia

Esophageal Varices Grade II

Based upon:
Anamnesis: Hematemesis melena, malaise, history of jaundice,
history of anemia, nausea and vomiting, history of previous
ligation.
Physical examination: Anemic conjunctiva +/+, ichteric sclera +/
+, distended abdomen.
Supporting examination: EGD shows presence of varices
esophagus grade II, low Hb (10.1). low Ht.

Considered:
Varices esophagus gr II pro ligation ec. liver cirrhosis.

Diagnostic plan:
EGD, CBC, AST/ALT, vital si, observation of bleeding signs.

Treatment plan:
Pro ligation
Propanolol 2x10 mg
Educate the patient regarding his condition, advise the patient to
bed rest, avoidance of stress and dangerous bleeding signs.

Cirrhosis

Based upon:
Anamnesis: History of jaundice, hematemesis melena, nausea
vomiting, history of varices esophagus with ligation.
Physical examination: Distended abdomen, sclera icteric +/+
Supporting examination: -

Considered:
Liver cirrhosis ec suspected hepatitis

Diagnostic Plan
PT/APTT, AST/ALT, HbsAg, HCV

Treatment Plan

Liver diet 1890 KCal/day

Propanolol 2x10 mg
Vit K 3x1 amp
Educate the patient regarding his disease and prompt
consumption of liver diet to help maintain liver function.

Type 2 Diabetes Mellitus

Based upon:
Anamnesis: History of blood glucose level: 300 and diagnosis of diabetes
mellitus in Puskesmas in 2003. Waking up at night to urinate 2-3x per day
(polyuria), controlled using metformin but poor compliance.
Physical examinations: Supporting examination: GDS: 144

Considered
Diabetes mellitus type 2 controlled with metformin

Diagnostic Plan
Oral glucose tolerance test, HbA1c, GDS, GDP, GD2PP

Treatment plan
Continue active movement and exercise for 30 minutes per day or 150
minutes per week. Recommend low intensity exercise to avoid exacerbation
of bleeding from varices esophagus.

Diet DM 1890 Kcal

Educate the patient regarding diabetes mellitus as a lifelong disease, the
importance of prompt medication consumption, active daily living and
balance diet.
Continue metformin 3x500 mg before meal consumption.

Anemia
Based upon:
Anamnesis: weakness/malaise
Physical examination: anemic conjunctiva
Supporting examination: Hb 10.1

Considered
Anemia due to blood loss from varices
esophagus dd anemia of chronic disease due to
cirrhosis and diabetes mellitus.

Diagnostic Plan
CBC, TIBC, serum feritine.

Treatment Plan
Increase intake

D=

LITERATURE REVIEW
&
DISCUSSION

Hematemesis
Most likely upper gastrointestinal
bleeding proximal to the ligament
of Treitz
Most common causes: ulcers and
varices

Barkun AN, Bardou M, Kuipers EJ, Sung J, Hunt RH, Martel M, et al. International consensus
recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Annals
of internal medicine. 2010;152(2):101-13.

Hematemesis: Important
Assessment

Symptoms
Peptic ulcer: Epigastric or right
upper quadrant pain
Esophageal ulcer: Odynophagia,
gastroesophageal reflux, dysphagia
Mallory-Weiss tear: Emesis, retching,
or coughing prior to hematemesis
Variceal hemorrhage or portal
hypertensive gastropathy: Jaundice,
weakness, fatigue, anorexia,
abdominal distention
Malignancy: Dysphagia, early
satiety, involuntary weight loss,
cachexia

Past medical history

Varices or portal hypertensive
gastropathy in a patient with a
history of liver disease or alcohol
abuse
Aorto-enteric fistula in a patient with
a history of an abdominal aortic
aneurysm or an aortic graft
Angiodysplasia in a patient with
renal disease, aortic stenosis, or
hereditary hemorrhagic
telangiectasia
Peptic ulcer disease in a patient
with a history of Helicobacter pylori,
nonsteroidal anti-inflammatory drug
(NSAIDs) use, or smoking
Malignancy in a patient with a
history of smoking, alcohol abuse,
or H. pylori infection
Marginal ulcers (ulcers at an
anastomotic site) in a patient with a
gastroenteric anastomosis

Cappell MS, Friedel D. Initial management of acute upper gastrointestinal bleeding: from initial
evaluation up to gastrointestinal endoscopy. The Medical clinics of North America.
2008;92(3):491-509, xi.

Hematemesis: Important
Assessment

Comorbid Illness
Make patients more susceptible to
hypoxemia (eg, coronary artery
disease, pulmonary disease). Such
patients may need to be maintained
at higher hemoglobin levels than
patients without these disorders.
Predispose patients to volume
overload in the setting of fluid
resuscitation or blood transfusions
(eg, renal disease, heart failure).
Such patients may need more
invasive monitoring during
resuscitation
Result in bleeding that is more
difficult to control (eg,
coagulopathies, thrombocytopenia,
significant hepatic dysfunction). Such
patients may need transfusions of
fresh frozen plasma or platelets.
Predispose to aspiration (eg,
dementia, hepatic encephalopathy).
Endotracheal intubation should be
considered in such patients.

Past medical history

Varices or portal hypertensive
gastropathy in a patient with a
history of liver disease or alcohol
abuse
Aorto-enteric fistula in a patient with
a history of an abdominal aortic
aneurysm or an aortic graft
Angiodysplasia in a patient with
renal disease, aortic stenosis, or
hereditary hemorrhagic
telangiectasia
Peptic ulcer disease in a patient
with a history of Helicobacter pylori,
nonsteroidal anti-inflammatory drug
(NSAIDs) use, or smoking
Malignancy in a patient with a
history of smoking, alcohol abuse,
or H. pylori infection
Marginal ulcers (ulcers at an
anastomotic site) in a patient with a
gastroenteric anastomosis

Cappell MS, Friedel D. Initial management of acute upper gastrointestinal bleeding: from initial
evaluation up to gastrointestinal endoscopy. The Medical clinics of North America.
2008;92(3):491-509, xi.c

Esophageal Varices

Garcia-Tsao G, Sanyal AJ, Grace ND, Carey WD. Prevention and management of
gastroesophageal varices and variceal hemorrhage in cirrhosis. The American journal of
gastroenterology. 2007;102(9):2086-102.

Liver Cirrhosis

Heidelbaugh JJ, Bruderly M. Cirrhosis and chronic liver

failure: part I. Diagnosis and evaluation. American
family physician. 2006;74(5):756-62.
Heidelbaugh JJ, Sherbondy M. Cirrhosis and chronic liver
failure: part II. Complications and treatment. American
family physician. 2006;74(5):767-76.

Type 2 Diabetes Mellitus