CLINICAL CASE

A 56-year-old male was admitted to hospital via the accident and emergency department with a 1-day history of nausea and 'coffee ground' vomiting. In the previous 18 months the patient had undergone extensive investigations for anemia that had included six esophagogastroduodenoscopies and a colonoscopy. A barium follow-through study (which demonstrated Meckel's diverticulum) and a normal radioisotope Meckel's scan had also been performed. The working diagnosis was anemia secondary to blood loss and, because no notable source of bleeding was identified in the upper gastrointestinal tract or colon, a capsule endoscopy was planned to look for a cause of bleeding in the small intestine. The patient had been admitted to hospital on several occasions during this 18-month period and had received 30 units of transfused blood. His medical history included colonic polyps (cleared during three colonoscopies in a 5-year period before the onset of anemia) and diet-controlled type 2 diabetes mellitus, which had been diagnosed 14 years previously when it had also been noted that his alcohol intake was high. At the time of his current admission, the patient stated that his alcohol intake during the past 2 years had been 1 unit a day.

Examination revealed a fully conscious and lucid individual who seemed to be well nourished and who had a normal BMI. The patient's breath smelt of alcohol, however, and recent high levels of alcohol consumption were confirmed with a measured blood alcohol level of 286 mg per 100 ml blood. Icterus, conjunctival pallor, bruising and multiple spider nevi were present. The patient's blood pressure was 110/50 mmHg with no postural drop and his pulse was 90 beats/min in sinus rhythm. The results of a chest examination were unremarkable. No organomegaly was palpable in the abdomen and the results of a rectal examination were normal.

A full blood count confirmed the presence of anemia; the patient had a hemoglobin level of 66 g/l (normal 130–165 g/l), mild macrocytosis (mean corpuscular volume menor a 101fl) and thrombocytopenia (66 X 10⁹ platelets/l blood). A blood film was taken from the patient and was found to be markedly abnormal owing to the presence this cel (figure 1).

Hematinics were normal, but the results of liver function tests were (tabla 1). Splenomegaly was excluded by ultrasound examination of the abdomen; however, the texture of the liver appeared coarse. A sudden rise in the patients' serum bilirubin concentration to 148 umol/l (8.7 mg/dl) on the third day after admission combined with the presence of microspherocytosis (fugure e) raised the possibility of hemolysis. This diagnosis was supported by the finding of an increased unconjugated bilirubin level (from approximately 20–30% in the patient to a peak of 74%), an elevated lactate dehydrogenase level of 557 U/l (normal values), and a low haptoglobin level of 50 mol/l (500 mg/dl) (normal values).

Lewis G et al. (2007)

COMENTE EL CASO (DIAGNOSTICO, ETIOLOGIA Y TRATAMIENTO)