68 yo woman enters hospital because of abdominal pain and vomiting blood at home. EGD shows 5cm cratered ulcer in the fundus with a protruding visible vessel that was not actively bleeding. Treated with epinephrine injection and Nexpowder hemostatic spray. G.I says not amenable to clipping. Also per GI "she is high risk for rebreeding." The last Progress Note 4 days later at 6pm states "No c/o pain or discomfort." She is back on solid food and for dinner that night had Salisbury steak. At midnight, 6 hours later, she is found unresponsive with blood covering her mouth, neck, and upper chest. She is pronounced about 90 minutes later. Death certificate states cause of death was "hypovolemic shock caused by acute blood loss from a gastrointestinal bleed." Should she have been given serial scans?
Should she have been on telemetry? Should she have been checked on more frequently? Any departure diminish her chance of survival?
Files:
Q: How often was the patient's vital signs being taken? How may CBC blood counts were performed prior to the final bleeding episode? Was the GI consultant seeing the patient daily?
A: Pt.coded midnight 4/10.Last CBC was 4/9 at 0845.HCT was 33.8 (drop of 2.2 from 4/8) & HGB was 12 (drop of .8). Lasy GI consult was 4/6. Last vitals 19 minutes before Code. B/P 174/87.
Do you believe there might have been medical error?
Sounds like the ulcer was in a difficult position for other hemostatic options and they did apply two methods for this high risk lesion, which is generally speaking the standard of care. I’m assuming she was also on anti acids. There are no protocols regarding second look Endoscopy necessarily and depends on how the patient is progressing clinically. Her re-bleeding four days later implies that the initial efforts were likely successful and she was in the process of healing. This is a very rare but unfortunate outcome and I’m not sure that any different pathway would’ve prevented her exsanguination.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
See above. If there was any evidence of ongoing bleeding after the initial endoscopy, then additional methods and or approaches should have been applied, but that would depend on a review of the records. The fact that she had a solid meal has no impact on her outcome as far as I can tell.
What makes you a good expert for this case?
20 years of clinical experience
How often do you encounter cases similar to this one in your practice?
It is extremely rare to bleed to death in an inpatient setting, but it can happen.
Do you believe there might have been medical error?
Issues to be determined 1. insufficient PPI therapy, Rebleed is a risk in elderly of approx 10% for 30 days
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
depends on dosinf and monitoring of first 3days and trending HCT
What makes you a good expert for this case?
experience and success record over 40 years
How often do you encounter cases similar to this one in your practice?
I no longer practice in hospital medicine
Do you believe there might have been medical error?
A visible vessel requires treatment with clips or cautery. Epinephrine is used to slow down bleeding so that the bleeding site can be visualized and treated. Hemostatic sprays can be used with active bleeding but not effective when there is just a visible vessel. It is possible that with just proton pump inhibitor and close monitoring the ulcer could become clean based but this would require close monitoring with repeat upper endoscopy. If the lesion was not amenable to therapy, embolization should also have been considered as an option
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The presence of a visible vessel makes releasing a significant risk. The failure to adequately treat the visible vessel likely led to rebleeding and her death
What makes you a good expert for this case?
I am a practicing gastroenterologist seeing patients both inpatient and outpatient. Upper GI bleeding due to peptic ulcer disease is a routine consult seen on any inpatient GI service and have treated many patients with either bleeding ulcers or stigmata of recent bleeding like a visible vessel
How often do you encounter cases similar to this one in your practice?
I cover the inpatient service about four times a year and routinely see upper GI bleeding. Some of these ulcers heal with just PPI therapy but many require therapy with clips or cautery and if refractory to these therapies or not amenable to these therapies, consideration of IR embolization or surgery
Do you believe there might have been medical error?
This was a relatively late rebleed assuming she was stable prior to this final episode
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There was likely no medical error. However I cannot be sure without review of records to see whether vital signs and routine CBC blood work were performed in the four days prior to the final bleeding episode and death
What makes you a good expert for this case?
Long term experience caring for patients with gastrointestinal bleeding
How often do you encounter cases similar to this one in your practice?
Infrequently now (less than one per year average) as my practice generally focuses on outpatient GI care
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