The Search Is On

A CLINICAL PROBLEM-SOLVING article by Molly Perencevich from Brigham and Women's Hospital, Boston.
An 81-year-old man presented to the emergency department with hematochezia and hematemesis, which began after he was awakened by an urgent need to move his bowels. initially, he had diarrhea with brown stool. Soon afterward, he again had urgency, and this time red blood filled the toilet bowl. He later vomited a small amount of blood. He did not have abdominal pain, black stools, dysphagia, or odynophagia. The patient's medical history included unstable angina treated 3 months earlier with placement of a drug-eluting coronary stent.
On physical examination the patient appeared fatigued. While he was supine, the heart rate 55 beats per minute, the blood pressure 122/60 mm Hg. When he stood up, the heart rate increased to 83 beats per minute and the blood pressure was 118/62 mm Hg.
No cause of the gastrointestinal bleeding was apparent on upper endoscopy. CT showed the prior aortoiliac repair but no evidence of an aortoenteric fistula or graft infection. The patient no longer appeared to be bleeding when the CT was performed; however, approximately 24 hours later, he had an episode of hematochezia and hematemesis.
In this case, given the patient's recurrent hematemesis and the results of the evaluation so far, the source of the bleeding seemed most likely in the proximal small bowel. [Original Article]