QUIZ: Vomiting blood

Saturday, 12 December 2009 17:43

Case Description: A woman was admitted to ED due to vomiting blood. The patient is conscious, complains of headaches and periodical loss of consciousness. She showed signs of an epileptic seizure in the ambulance.

Quiz questions: What are your suspicions? What do you do?

Comments

0 #1 drmark15 2010-04-06 06:04

increased intracranial pressure. do some CT head, electrolytes, and eeg.

0 #2 Gonzo 2010-04-11 14:24

CT head, electrolytes and EEG - without abnormalities. It isn't increased intracranial pressure.

0 #3 drmark15 2010-04-11 17:08

is there any pain the patient experiences? ..i suspect alcohol intoxication.

0 #4 Gonzo 2010-04-12 12:05

As I wrote in case description - the patient complains about headaches.
She claims that she doesn't drink alcohol.

0 #5 marios70 2010-06-09 12:46

She vomited blood so she could be in a shock condition. Take her BP and heart rate, do a rectal exam to see signs of blood in the stool, and a complete blood count to evaluate her Hct...

0 #6 drmark15 2010-06-25 07:12

do EEG..

+1 #7 Emily 2010-12-20 15:33

I'd consider a blood smear for p. falciparum infection which could explain the vomiting (coagulopathy) and altered consciousness (cerebral malaria).

I would order full liver function tests to confirm (more or less) that the patient is telling the truth about not drinking.

I would also ask about NSAID use - maybe the headaches are the cause of NSAID overuse and otherwise unrelated to the hematemesis.

0 #8 Ahmad qtaifan 2010-12-31 18:39

It might be gastric ulcer ,what about her medical history , ask her if she had thrombus and if she was taking asprine which is the common cause for gastric ulcer .

0 #9 Ahmad qtaifan 2010-12-31 18:41

And about headach it could be a previous cerebral infarction

0 #10 denag14 2011-01-02 00:37

This lady has a problem with the brain (brain injury due to infarction, increased intracranial problem,tumor). As such an EEG, MRI or any appropriate imaging technique of head together with an intensive history could help localize the source of disease.

predicted pathogenesis: the brain problem (whatever the cause maybe) has lead to the increased headache and periodic loss of consciousness and epileptic siezures. This has subsequently lead to stimulating of the vomiting centre, resulting in vomitus and blood production, a condition known as Mallory-Weiss tear;

0 #11 DocFlynn 2011-01-07 02:22

ruptured cerebral aneurysm..Head CT followed by cerebral angiography. surgery with aneurysm clipping..most likley the pt. ruptured cerebral anurysm, and we might want to choose stroke over cerebral anurysm. here anurysm is more likly, as well as you would expect to see neuro focal findings w/ stroke, not present here ischemic cerebrovascular accident --> expect to see some focal signs as well as TIA, usually transient and other symptoms present , I would need a little more info like vitals & blood work a more detailed history. Were there siezures or was she diagnosed with epilepsy prior to the headaches or vomiting of blood??? If so then I would start looking for esophageal issues. From detachment to cancer.

0 #12 Gonzo 2011-02-08 14:21

BP 130/70, heart rate 80/min.
In rectal examination there is no blood.
EEG, MRI, CT are normal.
Blood smear for plasmodia - negative
You have right that there is a problem with the brain, but must it be an organic disease? Think about this.

0 #13 katia 2011-04-14 04:00

after rule out of organic disease,i think she has a mental illness.maybe vomiting blood is due to self-injury or bite of her tongue during the epilepsy! consult with a psychiatrist and psychologist.

0 #14 chickpee 2011-04-19 17:55

Here is a zebra--neurocysticerco sis. She has eaten undercooked pork...saw it in autopsy once...

0 #15 dr.premanand@gmail.com 2011-05-11 20:01

why wouldnt it show up as ring enhancing lesion?

0 #16 chickpee 2011-05-12 14:21

Well, it might not depending on it's developmental stage or location in the brain...

0 #17 player13.presh 2011-05-13 03:05

what if its two different disorders affeting the CNS and whatever is causing the bleeding?? like she may have headaches for which she was taking either acetaminophen or aspirin...both on chronic use can cause bleeding due to esophageal varices and peptic ulcers respectively...as for the CNS...she could have transient ischeamic attacks or even migraine...though why she had the siezure is still a question...perhaps more suggestive of a liver disorder?? all tht ammonia...discuss

0 #18 eleonora 2011-05-13 21:42

It could be an Osler-Weber-Rendu syndrom. Arteriovenous malformations in gastrontestinal tract and brain could cause haematemesis and epileptic seizures. It especially fits if the woman is young. In this case I would ask for family history of telangiectasias and do an endoscopy.

+2 #19 terrencekamvumbi 2011-05-14 11:50

hey doctors since when do you start giving differentials just like that, first you take the patient's history and order tests in contest with her history. but in the meantime you check for signs of heamodynamic shock and eventual aneimia do a CBC

+2 #20 eleonora 2011-05-14 19:30

Since she has BP 130/80 and HR 80/min and her shock index (pulse/systolic bp) is < 1,she is haemodynamicall y stable. I'd place an IV cannula and draw blood for FBC, urea levels to see if she is bleeding from upper GI, clotting, G&S and finally would do a gastroscopy.

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