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A 41 year old was admitted due to generalized body weakness and tarry stools.

He has a 2 month history of burning epigastric pain and a 2 week history of

coffee ground vomitus with melena.

He has a history of pulmonary TB and alcoholism. He reports early satiety and

weight loss of 50% in 2 months. Physical exam was unremarkable except for
direct epigastric tenderness.

These are the salient features of his case

Could this patient’s symptoms at this time have been due to a peptic
ulceration? Or could it have been something else?

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Bleeding can either be an upper or lower GI bleeding. With the patient

presenting with melena, coffee ground vomitus, bloody output from NGT, this
likely is from the upper GI. Melena is the rule, and 90% of melena points to the
upper GI.

In this case, we must decide as to whether this bleeding is variceal or non-

variceal in origin.

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Variceal bleeding may be caused by Schistosomiasis, an endemic disease in

Sorsogon, with the 3rd highest prevalence in the Philippines. These entities share
a common denominator of portal hypertension responsible for the bleeding.

Additionally, Marini et al reports that variceal bleeding usually presents with

painless bleeding, hematemesis, and with signs of chronic liver disease.

In the absence of these, we look into other differential diagnosis.

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It is interesting to point out that during the course on the wards, abdominal
ultrasound revealed ascites but no other findings pointing to portal hypertension.
In the absence of splenomegaly and signs of collateral circulation, we look into
other differentials.
In contrast, a non-variceal bleeding typically presents with pain, vomiting of
coffee-ground material and melena. It is an umbrella term encompassing
vascular, infectious and neoplastic causes. Vascular lesions such as these are
considered, however they do not typically present with a massive bleeding
leading to anemia with the need for transfusion.

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Infections can also cause upper GI bleeding. An H Pylori infection can lead to a
bleeding peptic ulcer. An undetermined TB activity leads us to think of gastric
tuberculosis. This, although rare, can present with bleeding, weight loss, early
satiety, and abdominal pain. These infections cannot be totally ruled out unless
with specific diagnostics

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Neoplasms can be benign or malignant. Benigns lesions such as gastrinomas

which present as a peptic ulcer disease is ruled out. Malignant tumors can be
primary or metastatic, which are indistinguishable from each other. However,
the patient’s history and PE does not point to a tumor metastasizing to the

Malignant lesions can occur in any of these 3 anatomic locations: the

esophagus, stomach, or duodenum. Absence of dysphagia rules out an
esophageal lesion and absence of jaundice and signs of obstruction rules out a
duodenal lesion.

Left with the stomach, we considered primary and metastatic malignancies.

Metastes from other organs is indistinguishable from primary gastric cancers.
Prior to metastases, primary tumors are detected first, making this diagnosis less
likely. We consider the following pri mary tumors: gastric lymphoma, gastric
adenocarcinoma and gastrointestinal stromal tumor or GIST.

All these can potentially ulcerate – causing GI bleeding seen as melena and
coffee-ground vomitus. Additionally, constitutional symptoms such as abdominal
pain, weight loss, early satiety, and microcytic hypochromic anemia are seen.
What sets each other apart is their degree of bleeding. Of them, gastrointestinal
tumors are more likely to bleed massively.

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Putting this all together, we say that this man had GIST – a primary malignant
lesion causing massive non-variceal upper gastrointestinal bleeding.

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Gastrointestinal stromal tumors or GIST is the most common mesenchymal tumor

of the abdomen, mostly occurring in the stomach.

Majority of GISTs have cKIT mutations promoting cell growth.

Proliferation of the lesion produces mass effects explaining its clinical


The tumor alters mucosal blood supply, leading to cell necrosis, ultimately
causing ulcerative bleeding for chronic periods, seen as microcytic
hypochromic anemia. As a result, it presents with a burning epigastric pain.

Further growth of the lesion leads to

Symptoms and signs are related more to the site and mass of the tumor.

Bleeding is attributed to the erosion into the GIT lumen causing melena and anemia, usually an
indicator of chronic chronic on presentation.

Bleeding comprises the most common symptom after vague abdominal discomfort.

Most common sites of metastases of GISTs include the liver, lung, bone, and skin. This accounts
for the pulmonary and liver nodules seen on imaging.

Malignant cells producing growh factors increase capillary permeability leading to increased net
capillary fluid filtration. The cells themselves accumulate in vessels causing lymphatic
obstruction. The net effect of which is accumulation of peritoneal fluid – ascites.


Symptoms of GISTs at presentation may be related to mass effects. Mucosal

ulceration can cause blood loss, and approximately half of individuals with GIST
present with anemia or related symptoms
 Vague, nonspecific abdominal pain or discomfort (most common)
 Early satiety or a sensation of abdominal fullness
 Palpable abdominal mass (rare)
 Malaise, fatigue, or exertional dyspnea with significant blood loss
 Focal or widespread signs of peritonitis (with perforation)

GI bleeding is produced by pressure necrosis and ulceration of the overlying mucosa

with resultant hemorrhage from disrupted vessels. It can occur as a slow intraluminal GI
bleed or massive bleeding due to rupture of the tumor.

Significant blood loss reflects as a generalized body weakness.


Pulmonary nodule

Liver mass


Acute gastrointestinal bleeding would present a blood picture f normocytic

normochromic anemia. Isn’t it puzzling for the patient to be presenting on
admission with microcytic hypochromic anemia – which reflects a chronic blood
loss. We are considering this to be an acute on chronic blood loss (explain)
In the setting of acute blood loss,

In the setting of acute blood loss, anemia is usually normocytic, norchoromic.

What is

Patient presents with decreased hemoglobin and red cell indices –

characteristic of a microcytic, hypochromic anemia. (Journal)


He presents with decreased hemoglobin and red cell indices. This is

characteristic of microcytic hypochromic anemia. This can be attributed to
several causes including: ___________


On CBC, neutrophilia was noted. This can be due to:

Initially, the patients platelet count was normal, but after the 10th hospital day,
started to decline until it reached abnormal levels.

Metabolic Panel

Let us turn to his interesting blood chemistry. Initially, it was unremarkable. But, on
the 10th hospital day, his BUN was disproportionately elevated compared to
creatinine, increasing the BUN-creatinine ratio. Few days before his death, he
was found to be hyponatremic, and with an elevated direct bilirubin but normal
total bilirubin. His SGPT is normal.
Chest xray

TB of undetermined activity and a pulmonary nodule was found. Could the TB in

active or latent




Liver mass

The next possibility to be weighed

I shall use as a point of departure for my discussion the…….

If we accept the underlying diagnosis of gastrointestinal stromal tumors, there

are a few losse ends in this case that are not typical of the disease and require

Many of the clinical findings of this case can be attributed to upper gi bleeding

The terminal events were probably precipitated

I would like to say some remarks regrding the patinets… as the patient did not
have a history of bleeding problems, the assumption mustb be made that the
coagulopathy was acquired.

I’d like to say a few words at this point about the patient’s puzzling blood
chemistry during the course in the wards.

Initially, the patient’s BUN-creatinine ratio was normal, and on the 10th hospital
day, the BUN was disproportionately elevated relative to creatinine leading to
an increased BUN Creatinine Ratio.
This patient’s case can be characterized in one word – failure, with reference to
the liver, GI, and then the kidneys.

This man could have had a liver disease. He was a past alcoholic

Although splenomgaly apparently was not found, we think that this patient had
portal hypertension and that it was the cause of the esophageal varices, to
which we attribute the upper GI bleeding and anemia.

Given his history of alcohol abuse, the ascites was initially thought to be due to
portal hypertension, although he had no other signs or symptoms of chronic liver

This may be due to a multitude of causes, including: infectious, inflammatory,

neoplastic, vascular, and autoimmune.