1. SYB Case #2

2. G.C is a 90yr male who presents with sudden onset progressive weakness for the past 2 days. Experiencing epigastric pain for the past week with poor PO intake. 2 formed bowel movements per day. Black stool, no hematochezia. EGD was normal. History of taking aspirin and Relafen(NSAID) for knee osteoarthritis.

3. Labs Na 135 K 4.9 Cl 106 Bicarb 20 BUN54 Cr 1.05 Glucose 190 Ca 8.7 WBC 12.7 Hemoglobin 6.8 Hct 20.1 Platelets 313 PT 10.9 INR 1.04 PTT<20 ALT 13 Alkaline phosphatase 29 Lipase 187

5. X-Ray Abdominal Series Nonobstructive bowel gas pattern. No evidence of free air.

6. CT Pelvis and Abdomen with Contrast No etiology for patient’s black tarry stools and abdominal pain No evidence of obstruction No free fluid or free air Scattered vascular calcifications of the abdominal aorta

7. ZNMZ GI Bleeding Study Tc-99m labeled red blood cells Sequential abdominal images obtained through 90minutes Nuclear scintigraphy can detect hemorrhage at rates as low as 0.1 mL/min. Findings: accumulation of radiotracer within the small bowel progressing distally on the dynamic images with the origin likely at the duodenum or proximal jejunum.

9. 99m Tc-labeled RBC scintigraphy The bleeding site can be identified when intraluminal accumulation of 99m Tc-labeled RBCs is observed during the dynamic phase of scanning. Nuclear scintigraphy is sensitive enough to diagnose ongoing bleeding at a rate as low as 0.1 mL/min It is not highly accurate in locating the bleeding point. Provides approximate location only and best for bleeding beyond the ligament of Treitz. Most sensitive for lower GI bleeding.

10. Visceral Arteriogram Identification of vascular abnormalities and the precise bleeding point Catheter is inserted into the common femoral artery at the level of the groin and advanced to the superior mesenteric artery. The extravasation of contrast material indicates a positive study finding. Findings: Variant celiac anatomy with a replaced common hepatic artery arsing from the SMA. The gastroduodenal artery and its branches and the superior mesenteric artery and its branches, are normal. No site of active extravasation was identified. No early draining vein to suggest an area of angiodysplasia was identified. Impression: normal visceral arteriogram, without evidence of gastrointestinal hemorrhage.

11. Selective mesenteric angiography Mesenteric angiography remains the criterion standard in precise localization of the lower GI bleed. Selective mesenteric angiography can detect bleeding at a rate of more than 0.5 mL/min. Concentrate on the major mesenteric vessel most likely to be responsible (eg, the inferior mesenteric artery in bright red rectal bleeding). If no bleeding is identified, the other major mesenteric vessels, including the superior mesenteric artery and celiac axis, are studied. In some cases, aberrant vascular anatomy can contribute to colonic or small bowel circulation Once the bleeding point is identified, angiography offers potential treatment options, such as selective vasopressin drip and embolization

12. As of yesterday G.C is still in the hospital Arterial Duplex 1. No evidence of stenosis/occlusion identified in the common femoral or femoral arteries. 2. Occlusion of the popliteal, anterior tibial, posterior tibial, and peroneal arteries. 3. ABIs not obtained due to lack of pulses in the right leg and noncompessible tibial vessels in the left.