SURGERY 2nd CASE REPORT

NAME

: SHARVINDAN A/L SUBRAMANIAM

IC NUMBER

: 900309-05-5063

MATRIX NO : MBBS/DEG/2010/0102

PATIENT IDENTIFICATION
NAME : Gopalakrishnan s/o Venkateswaran
AGE: 56 years old
SEX: Male
ETHNIC GROUP: Indian
ADDRESS: Sg.Buloh
MARRITAL STATUS: Married with 3 children
OCCUPATION: School teacher
DATE OF ADMITTION: 15/12/2012
DATE OF CLERKING : 17/12/2012

CHIEF COMPLAINT
Patient came to Hospital Sungai Buloh on 15th of December 2012 with a
complaint of passing of dark coloured stool and per rectal bleeding for the
past one day associated with nausea.

HISTORY OF PRESENT ILLNESS

Mr Gopalakrishnan experienced bleeding in the morning when he
went to the toilet at about 9am in the morning. He woke up at 8am in the
morning and did gardening in his garden at home. While gardening, he
suddenly felt nauseated and tired, thus, he went and took a rest in the
house. He then had the sensation of passing motion and went to the
toilet. When passing motion, he noted a large amount of blood came out
together with the faeces and the toilet bowl was filled with fresh blood.
This was the first episode for him. The blood was bright red in colour and
there were no blood clots. There were no mucous. The stool was dark in
colour. The stool was normal in amount and there was no associated
abdominal pain. The patient

told that the blood was quite a lot but he was unable to

quantify the exact amount.

He then felt dizzy and almost fainted. He could not

wake up by himself after that incident.

His wife cleaned him and he was brought to the hospital by an ambulance
to the Emergency Department. In Emergency Department, his vital signs
were monitored and 1 pint of blood was transfused. Besides that, x-ray
and endoscopy was also done.
He normally goes to the toilet once daily, in the morning. There
were no changes in his bowel habits. He did not notice the colour of his
stool before. He had no urinary system symptoms. He had no vomiting. He
had no loss of weight or loss of appetite.
He does not exercise. He described his is diet low in oil and he eats
rice in the morning but does not eat anything at night.

ACCOMPANYING SYMPTOMS
He felt nauseated before passing motion. He experienced dizziness
and syncopal attack immediately after the bleeding. He also had
palpitation after the bleeding. He didnt experienced vomiting. He had no
fever. He had no hematemesis or hematuria.

PAST MEDICAL AND SURGICAL HISTORY

He was diagnosed with hypertension 8 years back and is under
medication. He also has diabetes for the past 8 years. Initially he was
taking oral hypoglycemic drug, now he is taking insulin for the past 4
years. His follow up is in Sungai Buloh Hospital. He has not done blood
transfusion before.

ALLERGIES AND DRUG HISTORY

He has no allergy to any medication or food. He is taking antihypertensive and insulin. Besides that, he is also taking aspirin for the

past five years. He takes quarter tablet every morning and he could not
remember the dose. He last took it one day before the bleeding.

FAMILY HISTORY
The patient does not know if the parent had any medical illness.
There is no history of similar problem or malignancy in his family. He has
five siblings and he is the eldest. One of his brothers has hypertension.

SOCIAL HISTORY
Mr Gopalakrishnan is married with 3 children. He works as a school
teacher in Sekinchan. He stays in a terrace house nearby with good
facilities. There is good supply of electricity and water. He told he is
comfortable with his living condition and it is clean.

REVIEW OF SYSTEM
a) General review : He was not in pain and was lying comfortably.
b) Respiratory system : He had no shortness of breath, flu or cough.
c) Cardiovascular system : He had no chest pain or difficulty in
breathing.
d) Musculoskeletal system : He had no joint pain or difficulty in
walking.
e) Genitourinary system : He had no difficulty, pain or noticed blood
while urinating.
f) Gastrointestinal system : He had no difficulty in swallowing. No
diarrhea or mucus noted by patient in his stool. However there was
large amount of blood together with the dark stool. There were on
associated abdominal pain.
g) Neurological system : Patient was not feeling dizzy,not under
depression or anxiety.

General Examination
Mr Gopalakrishnan is a well built male and was lying down in a supine position on
the bed with a pillow on his head. He was not in pain or discomfort.He was moderately
hydrated. His weight was 97kg, height was 168cm and BMI was 34.4 which suggests that he
is obese. He was conscious during the examination and aware of the time and place he was at
that time.
Upon vital signs, his temperature was recorded and it was 36.8 C, thus he was
afrebile. His blood pressure was recorded 139/72 mmHg and the pulse rate was 80 beats per
minute. His respiratory rate was 22 beats per minute. Examination of the hands revealed cold
hands, there was pallor, no clubbing, no cyanosis and no tar-stained nails. There was also no
palmar erythema on the hands. The capillary refill time was less than 2 seconds.
The face appears normal and its symmetrical. There was no pallor on both right and
left conjunctiva and no jaundice on the sclera of the eye. There was no any scar on the face.
Besides that there is no cyanosis, swelling, ulceration or dehydration seen inside the mouth,
lips and tongue. Examination of the neck revealed no enlargement of the thyroid gland and no
palpable lymph nodes within the cervical region. There was no pitting edema of lower limbs
up to the level of ankle.

ABDOMINAL EXAMINATION

On inspection, the abdomen was distended. There was no scar or surgical marks on
the abdomen. There was no presence of visible veins. The hair distribution was normal. The
umbilicus was inverted and centrally placed. The abdomen moves symmetrically with
respiration.
On light palpation of the abdomen, there was no tenderness at any region of the
abdomen. There was no guarding at any part of the abdomen. There was no rebound
tenderness on the abdomen.
Murphys sign was negative indicating there was no gall bladder involvement. There
was no Grey Turners sign in the flank or Cullens sign in the umbilicus seen. There were also
no rebound tenderness and Rovsings sign was negative.
Upon deep palpation on the abdomen, there was no pain. During palpation of the solid
organs, the liver appears normal, there was no enlargement and the liver span was 11cm.
There was no enlargement of the spleen and it is not palpable. The kidneys were normal, no
enlargement and its impalpable.
On percussion of the abdomen, it was resonance. There was no presence of shifting
dullness and no fluid thrill present. There was no ascites detected on percussion.
On auscultation, there were low-pitched gurgling sound heard and was 4 sounds per
minute. There were no abnormal bowel sounds heard.

DIAGNOSIS & DIFFERENTIAL DIAGNOSIS

DIFFERENTIAL DIAGNOSIS
1)
2)
3)
4)
5)

Symptomatic anemia secondary to upper gastrointestinal bleeding,aspirin induced.

Lower gastrointestinal bleeding
Hemorrhoids
Peptic Ulcer Disease
Systemic bleeding disorder

WORKING DIAGNOSIS

1) The stool was dark,tarry indicating bleeding was from upper gastrointestinal tract.
Patient also presented with syncopal attack immediately after the bleeding resulting
from high amount of blood loss.There had been occult blood in the stool which was
unnoticed.
2) Rectal examination was done and there was no mass noted.Patient did not feel
itchiness anywhere regarding perianal area.This excludes hemorrhoids.
3) Patient had no past history of gastritis before and no abdominal pain felt. Food intake
did not caused vomiting or pain in the abdomen.Thus,peptic ulcer disease can be
excluded.
4) Patient had no history of bleeding disorder such as hemophilia,excessive
anticoagulation or thrombocytopenia. Blood coagulation profile of the patient was
normal.Patient not suffering from any blood disorder.
5) Patient felt naused prior to the rectal bleeding.Stool was dark coloured and mucous
was absent. He also had syncopal attack immediately after the bleeding. This indicates
that there was internal bleeding from the upper gastrointestinal tract.Patient was also
under aspirin for the past 5 years.

DIAGNOSIS : Symptomatic anemia secondary to upper gastrointestinal bleeding, aspirin

induced.

INVESTIGATION
IMAGING
A ) ULTRASOUND ABDOMEN
The liver was normal in size and echotexture. There was no focal lesion. Intrahepatic ducts
and common bile duct were not dilated. Gallbladder was well distended and there was no
calculi or polyps within it. Spleen was normal,no enlargement detected.Kidneys were normal
in size and echogenicity,Bipolar lengthS and cortical thickness-right kidney 9.1/0.7cm and
left kidney 10.2/1.0cm. There was no calculi or hydronephrosis bilaterally.Urinary bladder
appears grossly normal. Prostate was not enlarged. The appendix wall appeared normal.
Pancreas appeared normal.
B) Colonoscopy

LABORATORY

Full Blood Count (FBC)

Result

Normal
Impression
range
White Blood Cell
21.9 x 10^9/L
4.00 - 11.00
Red Blood Cell
5.10 x 10^12/L
4.50 - 5.50
Haemoglobin
15.8 g/dL
13.0- 17.0
Haematocrit
50.3 %
40.0 - 54.0
Mean Cell Volume
88.5 fl
83.0- 101.0
Mean Cell Haemoglobin 29.4 pg
24.0- 33.0
Mean Cell Haemoglobin 33.2 g/dL
31.0- 37.0
Concentration
Red Cell Distribution
13.9 %
11.5- 14.5
Width
Platelet
128 x10^9/L
110-450
Percentage Of
75.4 %
40.0-80.0
Neutrophil
Percentage of
22.2 %
20.0- 40.0
Lymphocyte
Percentage Of
7.7 %
2.0- 10.0
Monocyte
Percentage Of
1.0 %
1.0- 6.0
Eosinophil
Percentage of Basophil
0.3 %
0.0- 2.0
Absolute Neutrophil
1.90- 8.00
6.02 x 10^9/L
Absolute Lymphocyte
1.74 x 10^9/L
0.90- 5.20
Absolute Monocyte
0.95 x 10^9/L
0.16 -1.00
Absolute Eosinophil
0.00- 0.80
0.40 x 10^9/L
Absolute Basophil
0.03 x 10^9/L
0.00-0.20

Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal

Cardiac Enzymes
Result

Normal
Impression
range
Aspartate Transaminase 28 U/L
5-34
Lactate Dehydrogenase 148 U/L
125-220
Creatine Kinase
34 U/L
30-200

normal
normal
normal

Lipid Profile
Result
Triglycerides
LDL Cholesterol
HDL Cholesterol
Cholesterol

Normal
range
0.34
0.88
0.34
4.93

Impression
mmol/L
mmol/L
mmol/L
mmol/L

0.000.000.000.00-

1.70
1.95
1.03
5.20

normal
normal
normal
normal

Renal Profiles
Result
Urea
Sodium
Potassium
Chloride
Creatinine

Normal
Impression
range
13.3 mmol/L
3.2 - 7.4
136 mmol/L
136- 145
4.70 mmol/L
3.50- 5.10
100.0 mmol/L
98.0- 107.0
165.5 umol/L
64.0- 111.0

Abnormal
normal
Normal
Normal
Abnormal

Liver Function Tests (LFT)

Result

Normal range

Protein, Total
Globulin
Albumin/Globulin Ratio
Bilirubin, Total
Alanine
Transaminase(SGPT)
Albumin
Alkaline Phosphatase
Magnesium

Impression

88.0 g/L
48 g/L
0.83
42.9 umol/L
35 IU/L

64.0 - 83.0
19-33
1050 IU/L

Abnormal
Abnormal
Normal
Abnormal
Normal

40 g/L
83 U/L
0.77 mmol/L

35-50
40-150
0.66 -1.07

Abnormal
Abnormal
Normal

1.2 - 1.5

3.4 - 20.5

Phosphate Inorganic

0.69 mmol/L

0.74 - 1.52

Abnormal

Bilirubin Total and Direct

Result
Bilirubin, Direct
Billirubin, Indirect
Bilirubin, Total

Normal
Impression
range
7.1 umol/L
0.0- 8.6
26.6 umol/L
0.2-0.7 mg/dL
7.2 umol/L
3.4- 20.5

Normal
Normal
Normal

MEDICATIONS
i)Esomeprazole 40 mg tablet twice a day for 42 days
ii) Prazocin (5g)
iii) Perindopril (4mg)

SUMMARY
Mr Gopalakrishnan came to Hospital Sungai Buloh on 15th of November
2012 with a complaint of passing of dark coloured stool and per rectal
bleeding for the past one day associated with nausea. He had
hypertension and diabetes. He was under aspirin for the past 5 years. On
physical examination, there was no significant finding. There were several
investigations carried out such as full blood count, lipid profile, renal
profile, CT scan, abdominal ultrasound, electrocardiogram, colonoscopy
and liver function test.

Discussion
Gastrointestinal bleeding
Gastrointestinal (GI) bleeding refers to any bleeding that starts in the gastrointestinal tract.
Bleeding may come from any site along the GI tract, but is often divided into:

Upper GI bleeding: The upper GI tract includes the esophagus (the tube from the
mouth to the stomach), stomach, and first part of the small intestine.

Lower GI bleeding: The lower GI tract includes much of the small intestine, large
intestine or bowels, rectum, and anus.

Considerations
The amount of GI bleeding may be so small that it can only be detected on a lab test such as
the fecal occult blood test. Other signs of GI bleeding include:

Dark, tarry stools

Larger amounts of blood passed from the rectum

Small amounts of blood in the toilet bowl, on toilet paper, or in streaks on stool
(feces)

Vomiting blood

Massive bleeding from the GI tract can be dangerous. However, even very small amounts of
bleeding that occur over a long period of time can lead to problems such as anemia or low
blood counts.
Once a bleeding site is found, many therapies are available to stop the bleeding or treat the
cause.
Causes
GI bleeding may be due to conditions that are not serious, including:

Anal fissure

Hemorrhoids

However, GI bleeding may also be a sign of more serious diseases and conditions, such as the
following cancers of the GI tract:

Cancer of the colon

Cancer of the small intestine

Cancer of the stomach

Intestinal polyps (a pre-cancerous condition)

Other possible causes of GI bleeding include:

Abnormal blood vessels in the lining of the intestines (also called angiodysplasias)

Bleeding diverticulum, or diverticulosis

Crohn's disease or ulcerative colitis

Esophageal varices

Esophagitis

Gastric (stomach) ulcer

Intussusception (bowel telescoped on itself)

Mallory-Weiss tear

Meckel's diverticulum

Radiation injury to the bowel

Tests that may be done to find the source of the bleeding include:

Abdominal CT scan

Abdominal MRI scan

Abdominal X-ray

Angiography

Bleeding scan (tagged red blood cell scan)

Blood clotting tests

Capsule endoscopy (camera pill that is swallowed to look at the small intestine)

Colonoscopy

Complete blood count (CBC), clotting tests, platelet count, and other laboratory tests

Enteroscopy

Sigmoidoscopy