College of Pharmacy
This is an unusual presentation of stress ulcer. Look over the case, to have an idea of a real-life case of the condition you have covered in lecture.
Maycock, Mary Ann RN, BSN. A
Five-Year-Old Boy with Hematemesis. Journal of Emergency Nursing.
22(5):454-456, October 1996
Five-year-old Scott was transported from another facility by helicopter to our pediatric emergency department at 7:05 AM. His pajamas were covered with blood, and he was pale and anxious. He did not appear to be in any pain. His mother said that he had had a tonsillectomy 9 days ago. She also stated that Scott had been seen in our emergency department 2 days before because he was vomiting blood. At that time, he was kept overnight and discharged to home the next day. Scott had begun to vomit bright red blood again during the night, and his mother took him to the closest emergency department.
Scott's initial vital signs included a tympanic temperature of 36.5 degrees C, pulse 154 beats/min, respiratory rate 28 breaths per minute, and blood pressure of 101/44 mm Hg. His weight was 17 kg. On arrival in our emergency department, Scott was receiving oxygen per nasal cannula at 2 L/min, and had two peripheral IV sites at a keep-open rate. He had already received a 20 ml/kg bolus of lactated Ringer's solution, and his vital signs were stable en route to the emergency department.
Our assessment of Scott revealed a normal respiratory status. His capillary refill time was less than 3 seconds, and he appeared to be well hydrated. The cardiac monitor showed sinus tachycardia. He was responding appropriately for his age, cried, and reached for his mother during the examination. Results of the gastrointestinal (GI) examination were normal except for his mother's report of black tarry stools of unknown duration. His abdomen was soft, and bowel sounds were present and active in all four quadrants. The liver was not enlarged, and the genitourinary examination results were normal. Slight bruising was noted at both IV sites. The nurse caring for Scott thought that he was "a different kind of pale - not the kind you see in a child who is in acute shock." She also noted that the mother was hostile to the staff at times (yelling because Scott's underwear was cut off), and then apologetic. She left often to go outside. We attributed this to her stress and concern for her son.
Scott's mother reported no allergies to medications and told us that Scott was taking cefaclor (Ceclor) for prevention of infection, a dextromethorphan hydrobromide preparation (Poly-histamine DM) for cough, and acetaminophen for pain. His immunizations were current. His medical history included "stopped breathing because of a spider bite," the recent tonsillectomy/adenoidectomy, and chronic and unexplained anemia. The anemia might have explained his pale color. As an infant, Scott had failure to thrive. Because of his poor eating habits, low weight gain, and height he was in the 5th percentile on the physical growth chart. Scott had no history of bruising/bleeding and no family history of bleeding disorders. When we obtained the chart from his previous ED visit, we found that he had been taken to the operating room for control of postoperative bleeding. Only minimal bleeding was found, and he was observed overnight and discharged to home. His hematocrit at that time was 26.
Our interventions included frequent assessment of vital signs, and observation for any changes in neurologic status or decreases in blood pressure. His vital signs remained stable, and because he had no further bleeding in the emergency department, we maintained the IV lines at a keep-open rate. Laboratory test results showed hematocrit of 18, and a normal prothrombin and partial thromboplastin times. Chest x-ray results were normal except for a mild right upper lobe atelectasis. We kept him in an upright position and continued oxygen delivery at 2 L/min by cannula. We did not insert a nasogastric tube to avoid aggravating the bleeding. Scott showed no changes in his mental status during his stay in the emergency department.
Because we suspected a repeat episode of Scott's previous bleeding related to his tonsillectomy, we consulted with the otolaryngologist on call, who arrived to evaluate Scott. But was postoperative tonsillectomy hemorrhage the appropriate diagnosis?
The reported incidence of hemorrhage after adenotonsillectomy ranges from 0.1 percent to 8.1 percent. The frequency of major post-tonsillectomy hemorrhage requiring hemostatic surgery under general anesthesia is estimated to be 2.8 percent. Post-tonsillectomy hemorrhage can be classified as primary (occurring during the first 24 hours after surgery), or secondary (occurring after the first 24 hours). Secondary post-tonsillectomy hemorrhage occurs 5 to 10 days after surgery and often coincides with sloughing of the surgical eschar from the tonsillar bed. Secondary hemorrhages are usually less severe than primary hemorrhages but can be life threatening. Postoperative infections and poor eating habits may contribute to secondary postoperative hemorrhage. This diagnosis was the most obvious for Scott because of his history. He had already had one episode of bleeding within the 5- to 10-day period and had a markedly lower hematocrit, which suggests acute blood loss. His history of poor eating habits made him a likely candidate for infection, slower healing, and possible dislodging of the eschar tissue. However, visual examination in the emergency department by the otolaryngologist detected no active tonsillar bleeding.
Other possible diagnoses included several types of upper GI bleeding including esophageal varices, and mucosal lesions such as esophagitis, gastritis, peptic ulcerations, Mallory-Weiss syndrome, and stress ulcers. Upper GI bleeding accounts for 90 percent of major GI bleeding. Scott had been vomiting bright red blood and had black, tarry stools, both of which are symptoms of upper GI bleeding.
Esophageal varices are uncommon in infants and young children. They may occur in older children as a complication of portal hypertension, jaundice, hepatitis, blood transfusion, chronic failure of the right side of the heart, and exchange transfusion are the most common causes of severe upper GI hemorrhage in this age group. The principal signs are recurrent profuse, bright red hematemesis, with signs of intravascular volume depletion. Even though Scott had no history of these conditions and he was younger than most children with esophageal varices, we considered the diagnosis because of his signs and symptoms. An angiogram was considered but was not done because of the urgency to transport him to the operating room.
Mucosal lesions such as esophagitis, gastritis, peptic ulceration, Mallory-Weiss syndrome, and stress ulcers also were considered. Mucosal lesions are the most common sources of GI bleeding in all age groups. Esophagitis and gastritis can be due to exposure to various substances (nonsteroidal antiinflammatory drugs, aspirin, iron, and caffeine), prolonged nasogastric intubation, repeated vomiting, coughing, or straining at stool. Some of Scott's history pointed toward this diagnosis. He had recent intubation for the tonsillectomy and had a history of poor eating habits and frequent coughing. These two diagnoses were rejected because results of the GI examination were normal, and we still had a strong suspicion of post-tonsillar hemorrhage.
A peptic ulceration in the mucosal wall of the esophagus, the stomach, in the pylorus, or in the duodenum can be caused by emotional distress, harmful bacteria, poor eating habits, irritating drugs or chemicals, or a combination of these factors. Although Scott had a history of poor eating habits and emotional stress because of his surgery and previous hospitalizations, he had no other contributing factors for this condition. We also considered but ruled out Mallory-Weiss syndrome, which is caused by repeated violent vomiting and resulting mucosal tear and bleeding at the gastroesophageal junction. Scott had no such history.
Finally, we considered stress ulceration, usually associated with critical illness, physical trauma, burns, sepsis, or hemorrhagic shock. Acute, massive, and painless bleeding is frequently the first and only clinical manifestation of the disorder. Stress ulcers occur in all pediatric age groups. Scott's history and symptoms (the acute and painless bleeding) seemed consistent with this diagnosis, but the diagnosis of tonsillar hemorrhage seemed obvious.
Scott was taken to the operating room within an hour of his arrival in the emergency department. No active tonsillar bleeding was found. A bilateral carotid angiogram was performed with no evidence of bleeding. He received a blood transfusion and was transported to the pediatric intensive care unit. Only then did upper GI endoscopy performed in the pediatric intensive care unit reveal four or five gastric stress ulcers on the greater curvature of the stomach, with one actively bleeding. The otolaryngologist was surprised by this finding and came to the emergency department to show us pictures of the ulcers. Scott did well and was discharged home the next day, with plans for close follow-up and referrals to social services.
What did we learn from this case? We were humbled to be reminded that the obvious answer is not always the correct one. Despite the fact that we could find no symptoms of tonsillar bleeding, and none was found on the previous visit to the emergency department, we persisted with this diagnosis. We did not have much information about Scott's social situation (probably not too unusual in the ED setting). Later, we learned that even though he was not physically or mentally abused, Scott had had a very troubled 5 years of life. His mother was a drug addict and he was shuffled between different family members. Undoubtedly this factor, his prior hospitalizations, and his poor eating habits could have contributed to a stress ulcer. As practitioners, we tend to think of ulcers as an adult disease, but children may be affected more than we think by social situations.
Scott received the care he needed, and we treated his shock symptoms appropriately. However, this case taught me to ask, "Is the obvious the only possibility?"
Question:
During his previous hospitalization, if stress ulcer prophylaxis had been desired, what would you have recommended and why? Be specific, just like you were writing the order. Specify your monitoring parameters as well (efficacy and side effects.)