Today's case, reversed, caught the doctor a little off guard.
A 46-year-old female patient with the surname Fang.
Ms. Fang began to vomit blood that day for no reason, and there was a bout of nausea, and then her mouth was salty, and the blood gushed out, and the vomit was a mouthful of bright red blood.
But it frightened her.
Before and after vomiting several mouthfuls of blood, adding up to say that there is so much a small bottle of mineral water, hurry to the hospital.
The emergency department doctor Lao Ma received the patient, and it is estimated that he had to vomit at least 300ml of blood.
Vomiting blood is a rather random, unprofessional diagnosis, and the old horse must distinguish between patients in their busy schedule whether they are hematemesis or hemoptysis, which refers to blood from the digestive tract, such as esophagus, stomach, and duodenal bleeding; hemoptysis is tracheal and lung bleeding, carved out in the form of cough.
Doctor, hurry up and stop the bleeding for me, no matter what hematemesis and hemoptysis it is. Ms. Fang was anxious. She had only seen people vomit blood in the TV series, and she didn't expect to vomit blood today.
Lao Ma motioned to the nurse to first help the patient open the intravenous channel, start the rehydration, and then arrange for the nurse to draw her blood for testing.
Then ask the patient if he has ever had abdominal pain, bloating and other symptoms of peptic ulcers.
Ms. Fang nodded, saying that there were occasional abdominal pains before, but they were all in bursts, and it was fine for a few minutes, and she had not taken medicine.
Is there any tuberculosis? Bronchiectasis, etc.? The old horse asked again. These two are the most common causes of hemoptysis, the patient shook his head, said no, last year's unit physical examination took a chest x-ray, did not say that there is a problem with the lungs.
Judging from the patient's medical history and performance, it is not like hemoptysis, because she does not have an obvious cough, but there is nausea, so it should be gastrointestinal bleeding, it is hematemesis.
There are two most common causes of gastrointestinal bleeding, one is gastric ulcer, duodenal ulcer caused by bleeding, and the other is esophageal gastric variceal rupture bleeding due to cirrhosis.
Ms. Fang just remembered that she had hepatitis B, but the carrier, and the previous unit physical examination were all doing liver function, and it was not so bad that the liver cirrhosis did not know it.
It is this truth, if she has a physical examination every year, and also has a liver, gallbladder, pancreas, and spleen ultrasound, there is no reason not to find cirrhosis.
Have you ever had a gastroscopy, the old horse asked.
That's not.
That must be done today.
Ms. Fang's previous physical examination did not include gastroscopy, then there is no way to know whether there is a gastric ulcer, duodenal ulcer, etc., color ultrasound and chest x-ray can not be seen, must do gastroscopy.
I wanted to do it before, but I heard that it was so hard, so thick a pipe reached into my throat, I couldn't stand it. Ms. Fang was about to cry.
While talking, Ms. Fang came unexpectedly, went to the toilet, pulled out a few lumps of black stool.
Also took a picture to show the old horse, the old horse glanced at it, no need to test, this must be blood in the intestine, so the big is black, the stool is originally yellow, but if there is blood, the blood becomes black after digestion and decomposition.
Common sense that any doctor knows.
The fecal routine afterwards also confirmed the old horse's conjecture that the patient did have a lot of red blood cells in the stool.
After a quick infusion of 2 bottles of liquid, Ms. Fang felt better, also used hemostatic drugs, and did not bleed again.
Lao Ma asked the gastroenterologist to come down and said that the patient had gastrointestinal bleeding and was going to do it.
The gastroenterologist did the explanation work with Ms. Fang, worried that the bleeding would continue, and it was necessary to do a gastroscope to find the bleeding lesion and stop the bleeding, so as to be worry-free.
Ms. Fang still resisted, saying that she really did not dare to do gastroscopy.
Can do painless, anesthesia, a shot of people fall asleep. The doctor explained, but there is a risk, afraid that it will continue to vomit blood, causing suffocation, which is trouble.
Not doing it is also risky, and the risk is even greater, it is not clear whether the next time will be a big one, directly give people a shock, that is fatal.
Ms. Fang's husband also came, and after personal consultation, the two agreed to the gastroscope.
To do painless, anesthetic, Ms. Fang repeatedly confirmed, so the thick tube looks at the heart are afraid.
sign.
Ms. Fang was sent to the endoscopy room, and when a shot of propofol (anesthetic) went down, Ms. Fang fell asleep and fell down.
The gastroenterologist inserted the tube from her mouth and went all the way through her throat, esophagus, stomach, and duodenum.
The mucous membrane of the esophagus is still very clean, and there is no rupture of the esophageal varices, which is certainly not a problem with the esophageal veins.
There are still some blood stains in the stomach, which looks like old bleeding, and repeated viewing and irrigation have not found obvious bleeding foci.
Not a stomach ulcer.
What about the duodenum?
The gastroscope is nominally a gastroscope, but in fact, in addition to being able to see the esophagus and stomach, you can also reach in a little and see the duodenum below, and it is not far away.
The name of the duodenum is very strange, in fact, the origin of the name is also very simple, it is a piece of intestine, connected to the stomach, because this intestine has the surgeon's twelve fingers juxtaposed so long, so it is named duodenum.
Patients who do not have stomach ulcers are likely to have duodenal ulcers. Otherwise there is no way to explain her bleeding.
However, the gastroenterologist repeatedly looked carefully, and there was no obvious bleeding lesion in the duodenum.
Looking at it together, the patient may have a slight gastritis, far from the ulcer, and there is no way to explain the bleeding.
What's going on?
Could it be that the small intestine is bleeding deeper below the duodenum? The doctor wondered.
That's a bit troublesome, because the gastroscope is enough to see, and there is no way to stop the bleeding.
If you have to be clear whether it is the small intestine bleeding below, there are two ways, one is to do a capsule gastroscope, swallow a capsule with a camera, the capsule enters from the mouth, passes through the intestine, and then discharges through the anus, if there is real bleeding in the middle, the capsule endoscopy can see. But it can't handle it. We can only see if we can handle it.
There is a second way, that is, to send it over for interventional treatment, and through contrast, it may be possible to find bleeding from intestinal blood vessels.
Anyway, that's all an afterthought, and the current gastroscope didn't find a problem.
The gastroenterologist is preparing to exit the mirror and return home in mourning.
He scolded a foul language, as if to blame himself for misjudging.
The mirror exits all the way from the duodenum, through the stomach, esophagus, throat, mouth .....
Wait a minute.
Someone found a problem.
He pointed to the electronic screen and said that if he saw no, the patient's mouth had blood again. It was still clean when I first went in.
This is problematic.
Could it be the patient's mouth bleeding?
Thinking of this, everyone's back broke out in a cold sweat.
The gastroscopic lens scanned the patient's teeth a few times, and sure enough, the innermost large molar of the patient's teeth in the lower left was bleeding, and that tooth was estimated to be a caries.
Hurry up and find a dentist to come and see.
When the dentist looks at it, it is really a problem of teeth. The patient's teeth are somewhat loose, the gums are bleeding, and there are local redness and swelling, bleeding.
Oh my God.
Shouldn't the patient be vomiting blood caused by bleeding gums?
We have always thought that it is gastrointestinal bleeding, gastroscoscopy for a long time, can not find a problem, the more I do the more hairy in the heart. The gastroenterologist said.
In this way, the patient is really vomiting blood caused by bleeding gums.
Ended the gastroscopy.
The patient soon wakes up.
Fortunately, there was no more serious bleeding during the process, and it is estimated that the hemostatic drugs used in the emergency department were somewhat effective. But the bleeding was not completely stopped, and the patient's gums were still slowly oozing blood.
Ms. Fang explained that it is likely that the teeth and gums are bleeding, not the gastroduodenal problem, and let the dentistry deal with it.
The dentistry was examined and the bleeding stopped on the gums.
The results of the emergency department blood draw came back, the hemoglobin was a little low, the overall OK, and the coagulation indicators were still normal. It shows that the patient has no problem with blood clotting, and the bleeding is really only because of the problem of the gums, not the problem of blood clotting.
Everyone feels that the face is lost, and the patient's vomiting blood is not gastrointestinal bleeding, nor respiratory bleeding, but gum bleeding.
In general, gastrointestinal bleeding refers to the beginning of the esophagus to the end of the anus, and rarely considers the problems of the mouth. But in fact, the digestive tract includes the oral cavity. Therefore, the next time you encounter a patient who is considering gastrointestinal bleeding, you must take the oral cavity into account and routinely check whether the mouth may bleed.
Especially in some elderly patients, bleeding gums may not be self-aware and will mislead doctors.
Someone said, how much bleeding gums will occur? This is difficult to say. It is not necessary to have a coagulation disorder to bleed heavily. Encounter is encounter.
There is no danger.