Case 34-1995

Abstract

A 77-year-old woman was admitted to the hospital because of chronic gastrointestinal bleeding with increasing weakness and dyspnea.There was a 17-year history of gastrointestinal bleeding with an undetermined source, despite extensive evaluation on multiple admissions to this hospital that were characteristically complicated by severe anemia, with hematocrit levels as low as 13 percent, and congestive heart failure. Seven of the hospitalizations were during the two years before the current admission, and the most recent was four months before the current admission. During the 10 years before admission, the patient had received approximately 240 transfusions. Detailed panendoscopic examinations with angiographic studies 12 and 18 years before admission were unrevealing, and repeated upper and lower gastrointestinal endoscopic examinations in more recent years also failed to disclose the source of bleeding. During the three months before admission, the number of transfusions required increased to one or two every other week. Ten days before admission the patient had a hematocrit of 20 percent and was given two transfusions. After a day of improvement she had increasing weakness and dyspnea and was readmitted to the hospital.There was a history of chronic atrial fibrillation that was managed with digoxin; anticoagulant therapy was not considered a reasonable option. A cardiac ultrasonographic study, performed five months before admission, revealed left ventricular hypertrophy, with an ejection fraction of 61 percent and mild mitral regurgitation. The patient had had an appendectomy many years earlier. A right radical mastectomy had been performed 34 years before admission. She had had a stroke 25 years before admission, which resolved without residual problems. Twenty months before admission the patient had a bout of acute renal failure that was ascribed to treatment with trimethoprim-sulfamethoxazole, with an increase in the creatinine level to 3.7 mg per deciliter (330 m mol per liter); in recent months her base-line creatinine level had been 2.0 mg per deciliter (180 m mol per liter). An infiltrating ductal carcinoma of the left breast, demonstrated on biopsy nine months before admission, was managed by a lumpectomy; tamoxifen provoked nausea and vomiting and was discontinued. A left nephrectomy had been performed 30 years before admission, after multiple urologic procedures for urolithiasis. The patient had stopped smoking many years earlier and drank no alcohol. There was no history of hypertension, angina pectoris, or myocardial infarction.The temperature was 36.8 ° C, the pulse was 70, and the respirations were 28. The blood pressure was 150/80 mm Hg. The weight was 85.9 kg.On physical examination the patient was pale, massively obese, and in moderate respiratory distress. No lymphadenopathy was found. The head and neck were normal; the jugular venous pressure was obscured. Inspiratory crackles were heard over the lower third of both lung bases. The heart rhythm was irregular; S 2 was normally split, and a gr...