OBJECTIVES

To present a case of a 12-year old male who came in due to

melena

To discuss the approach to the diagnosis of a patient with

melena

To discuss Portal hypertension

GENERAL DATA
RN

12/M

Filipino

Roman Catholic

Pasig City
CHIEF COMPLAINT

Black stool
 HISTORY OF PRESENT ILLNESS

Abd Xray= PCMC Hema

Splenomegaly
Mass noted, left WA CT Scan =
Private clinic
abdominal area Splenomegaly
CBC = Anemia
BMA = (-)
6 years PTA
 HISTORY OF PRESENT ILLNESS

Abd Xray= PCMC Hema

Splenomegaly
Mass noted, left WA CT Scan =
Private clinic
abdominal area Splenomegaly
CBC = Anemia
BMA = (-)
6 years PTA
Abdominal Propanolol
Blood vomitus
Ultrasound
Dizziness
PCMC Vitamin K
Abdominal
Portal
discomfort
Hypertension Omeprazole
 HISTORY OF PRESENT ILLNESS

Interval
Bloody vomitus and stool PCMC Admitted
History
 HISTORY OF PRESENT ILLNESS

Interval
Bloody vomitus and stool PCMC Admitted
History

5 years PTA EGD with Rubber Band Ligation

 HISTORY OF PRESENT ILLNESS

Interval
Bloody vomitus and stool PCMC Admitted
History

5 years PTA EGD with Rubber Band Ligation (May 2014)

EGD with Rubber

Band Ligation
May 2015
Interval Bloody vomitus
PCMC admitted)
History and stool August 2017 July 2018

February 2019 May 2019

 HISTORY OF PRESENT ILLNESS

3 months PCMC
Black stools
PTA (Admitted)
 HISTORY OF PRESENT ILLNESS

2 months PCMC
Black stools
PTA (Admitted)

2 months
Follow-up check-up
PTA
 HISTORY OF PRESENT ILLNESS

2 months PCMC
Black stools
PTA (Admitted)

2 months
Follow-up check-up
PTA

Colds
8 days PTA Health Center Cetirizine Partial relief
(Watery)
 HISTORY OF PRESENT ILLNESS

2 months PCMC
Black stools
PTA (Admitted)

2 months
Follow-up check-up
PTA

Colds
8 days PTA Health Center Cetirizine Partial relief
(Watery)

2 days PTA Cough Health Center Lagundi No relief

 HISTORY OF PRESENT ILLNESS

5 hours Abdominal Black stool x 1

PCMC Admitted
PTA discomfort episode
 REVIEW OF SYSTEMS

General No fever | No developmental delay

No rashes, jaundice, pigmentation, active

Cutaneous
dermatoses
No eye redness/discharge, epistaxis, nasoaural
HEENT
discharge, dysphagia, oral ulcers

Respiratory No difficulty of breathing

Cardiovascular No cyanosis, chest pain, or palpitations

 REVIEW OF SYSTEMS
Gastrointestinal No diarrhea, constipation, changes in appetite

No discharge, hematuria, dysuria, decreased

Genitourinary
urine output
Musculoskeletal No bipedal edema, cramps

Hematopoietic No easy bruisability

Endocrine No polyuria, polydipsia, polyphagia

No seizure episodes, changes in behavior,
Neurologic headache, loss of consciousness, or weakness
BIRTH AND MATERNAL HISTORY

21 | G1P0

Regular prenatal check-up

No infections/illnesses

No exposure to
radiation/toxins
BIRTH AND MATERNAL HISTORY

21 | G1P0

Regular prenatal check-up

No infections/illnesses

No exposure to
radiation/toxins
 I FAMILY HISTORY

II

III

IV
FAMILY HISTORY
 IMMUNIZATION HISTORY

ADVERSE
VACCINE DOSE PLACE AGE
REACTIONS
BCG 1 Hospital Birth None
Hep B 1 Hospital Birth None
DTP-Hib-Hep B 3 Health Center 6, 10, 14 wks None
OPV 3 Health Center 6, 10, 14 wks None
PCV 3 Health Center 6, 10, 14 wks None
Measles 1 Health Center 9 months None
MMR 1 Health Center 1 year None
 NUTRITIONAL HISTORY

Exclusively breast
Does not skip meals
fed: 6 months

Complimentary food Avoids restricted

at 6 months food

Not a picky eater Preference for fruits

and vegetables
ENVIRONMENTAL HISTORY
 2 household members
 Well-lit, well ventilated one-
storey house
 Drinking water source:
refilling station
 Daily garbage collection
 No pets
 No exposure to smoke
 No history of travel
 PERSONAL-SOCIAL HISTORY
 Enjoys eating
meals with
 Grade 6
family
 Has a group of
 Good relationship  Non-picky eater
friends both girls
with his parents  Aware of food
and boys
 Close to his restrictions and
 Average
mother complies
academic
 Walks to and
performance
from school as
exercise

EDUCATION AND
HOME EMPLOYMENT
EATING AND EXERCISE
 PERSONAL-SOCIAL HISTORY

 Likes to draw and

read  Denies use of  Attracted to the
 He used to drugs and smoke opposite sex
always play  Denies friends  No girl friend
basketball but who use drugs  No crush in
was restricted and smoke school
due to condition

ACTIVITIES DRUGS SEXUALITY

 PERSONAL-SOCIAL HISTORY

 Denies
 Walks to school
melancholic
 Usually  Practicing
thoughts or any
accompanied by catholic
self-harming
mother to school
behaviors

SUICIDE SAFETY SPIRITUALITY

 PAST MEDICAL HISTORY

 No previous hospitalizations
 No other surgical operations
 No food and drug allergies
 CASE PRESENTATION
PHYSICAL EXAMINATION

Seen conscious, coherent, well-developed, fairly-

nourished, weak-looking, not in acute respiratory
distress with the following vital signs and
anthropometric measurements:

General Survey

Vital Signs Anthropometric Measurements

BP 90/60 Height 150 cm
Temperature 36.3 C Weight 35 kg
Heart Rate 82 bpm BMI 15.5
Respiratory Z score 0
23 cpm
Rate
O2 Saturation 98%
 CASE PRESENTATION
PHYSICAL EXAMINATION
 CASE PRESENTATION
PHYSICAL EXAMINATION
 CASE PRESENTATION
PHYSICAL EXAMINATION

SKIN

pallor, no cyanosis, no jaundice, warm to

touch, smooth with good skin turgor, no
palmar erythema, no clubbing of fingers
 CASE PRESENTATION
PHYSICAL EXAMINATION
 Normocephalic without any lesions and
scars;

 Anicteric sclerae, pale palpebral

conjunctivae;

 no ear discharges;
HEENT
 No alar flaring, no nasal discharges;

 Pale lips, moist oral mucosa, uvula at

midline, (-) hyperemic tonsils, (-) exudates
 CASE PRESENTATION
PHYSICAL EXAMINATION

supple, trachea at midline, no rigidity, thyroid

gland not enlarged, no lymphadenopathies, no
NECK jugular vein distention

CHEST and LUNGS

equal chest expansion, no retractions
equal tactile fremitus
resonant all over
Clear breath sounds
 CASE PRESENTATION
PHYSICAL EXAMINATION

HEART

Adynamic precordium, PMI is at 5th ICS, LMCL

No heaves or thrills
Distinct heart sounds, regular rhythm, no murmurs
 CASE PRESENTATION
PHYSICAL EXAMINATION
ABDOMEN

Slightly distended, no caput medusae

Normoactive bowel sounds
Soft, nontender
(-)Hepatomegaly
(+) Splenomegaly
 CASE PRESENTATION
PHYSICAL EXAMINATION

Not assessed

GENITALIA

(-) edema, no erythema of palms and

soles, CRT <2sec, full and equal pulses

EXTREMITIES
 SALIENT FEATURES

 12-year old
 Male  Pallor
 Bloody stools  Splenomegaly
 Portal hypertension
 WORKING IMPRESSION

Upper Gastrointestinal Bleed secondary to

Esophageal Varices secondary to
Portal Hypertension secondary to
Portal Vein Thrombosis;
Upper Respiratory Tract Infection
 PATIENT WITH GI BLEEDING
Hemodynamically stable?
No Yes

Acute History
stabilization - onset of bleeding
Secure airway, O2 - character of the blood
IV access/bolus - amount of blood
Type and cross - associated symptoms
Vitamin K - medication use
Nasogastric tube - history of prematurity
- personal and family history

Physical examination with emphasis

on:
- assessment of nasopharynx
- abdominal examination
- skin examination
 Confirmatory test for blood

Source of blood

Upper GI bleeding Lower GI bleeding

(hematemesis; melena) (hematochezia)

Swallowed blood?
(non-gastrointestinal source)

Yes No

Epistaxis Labs:
Procedures (dental, tonsillectomy) CBC with differential and platelets
Hemoptysis PT/aPTT
LFTs
BUN/Crea
Refer for endoscopy/imaging
 Labs

Mild/Chronic Bleeding Moderate Bleeding

- Admit for observation or - Hospitalize
discharge with close FU - Nasogastric tube
- Acid blockade - Serial hematocrits
- Consider sucralfate - Blood typing and screening
- Acid blockade

No
Continued bleeding? Wean supportive care as
Yes tolerated
Upper intestinal endoscopy Observe for evidence of
Identify/treat source of bleeding bleed
Rebleed

Malory Weiss tear Esophagitis/ BPUD Esophageal or Vascular

Gastritis/GER Gastric varices malformation
 Possible sources of bleeding

Mallory Weiss Esophagitis/Gastri BPUD Esophageal or Vascular

tear tis/GER Gastric varices malformation
 ADMITTING DIAGNOSIS

Upper Gastrointestinal Bleed secondary to

Esophageal Varices secondary to
Portal Hypertension secondary to
Portal Vein Thrombosis;
Upper Respiratory Tract Infection
 COURSE IN THE WARD

 CBC  Omeprazole
 NPO  PT APTT  Somatostatin
 D5IMB 56  Crossmatching  Vitamin K
 ALT AST  Blood
cc/hr  CXR transfusion
 COURSE IN THE WARD

 Hematemesis
 Cough  CXR: Negative
 Comfortable
COURSE IN THE WARD
COURSE IN THE WARD
 COURSE IN THE WARD

 Hematemesis
 Continue
 Cough  CXR: Negative
management
 Comfortable
CASE
DISCUSSION
 CASE DISCUSSION

PORTAL VEIN
Formed by the confluence of the splenic vein and
superior mesenteric vein
Drains the splanchnic blood from the stomach,
pancreas, spleen, small intestine and majority of
the colon to the liver
Normal pressure: 3-5 mmHg
 CASE DISCUSSION

PORTAL CIRCULATION
 CASE DISCUSSION

PORTAL HYPERTENSIONS
elevation of portal pressure >10-12 mmHg
Normal portal pressure : 7 mmHg
results from changes in portal resistance in
combination with changes in portal inflow

▲P = F x R
pressure gradient in the portal circulation (ΔP) is a
function of portal flow (F) and resistance to flow (R)
 CASE DISCUSSION

PORTAL HYPERTENSION
 CASE DISCUSSION

PORTAL HYPERTENSION
 CASE DISCUSSION

COLLATERAL CIRCULATION

 Gastroesophageal junction
 Anal canal
 Falciform ligament
 Splenic venous bed
 Left renal vein
 retroperitoneum
 CASE DISCUSSION

CLINICAL MANIFESTATIONS

• Most common presentation:

Bleeding from esophageal
varices

• Splenomegaly, sometimes
with hypersplenism

• Ascites
 CASE DISCUSSION

DIAGNOSIS
 Abdominal ultrasonography
 Doppler ultrasound
 Outlining the anatomy of the portal vein
 Excluding the presence of thrombosis
 Identifying the direction of portal venous blood flow
 Abdominal CT and magnetic resonance angiography
 Hepatic venography – most accurate method in determining
portal hypertension
 CASE DISCUSSION

DIAGNOSIS
 Endoscopy – most reliable method for detecting esophageal
varices
 CASE DISCUSSION

TREATMENT

 Fluid resuscitation – crystalloid infusion

 Replacement of red blood cells
 Correction of coagulopathy – Vit K, infusion of platelets of
FFP
 Nasogastric tube
 H2 receptor blocker or PPI
 CASE DISCUSSION

TREATMENT

• Vasopression
• Somatostatin
 CASE DISCUSSION

TREATMENT
 CASE DISCUSSION

TREATMENT
 CASE DISCUSSION

TREATMENT
 CASE DISCUSSION

TREATMENT
 CASE DISCUSSION

TREATMENT

• Nonselective beta blocker

• Propanolol (0.6-0.8 mg/kg/day) divided
in two-four doses
THANK YOU