Abdominal pain, black stools for half a month, the patient lost 10 kg...Where is the bleeding?

Only for medical professionals to read for reference.
Will you diagnose this type of gastrointestinal bleeding? Let's take a look at this case.

Case characteristics Jia Mou, male, 68 years old.
He was admitted to the hospital at 09:50:51 on February 16, 2021
with "abdominal pain, black stool for half a month.

"
Half a month ago, the patient had abdominal pain and black stool without obvious cause.
The abdominal pain was mainly whole abdomen, with intermittent attacks, accompanied by dizziness, fatigue, anorexia, nausea, vomiting, hematemesis, fever, chest tightness, shortness of breath and other discomforts, stool twice a day , It is black stool, and the amount is not clearly described.

Go to the local county people's hospital for related examinations, and the cause of bleeding was not clear.

Oral medication has no obvious effect.

The symptoms were getting worse.
In order to confirm the diagnosis, he came to our hospital and was admitted to the outpatient department with "gastrointestinal bleeding".

Since the onset of the onset, the patient has a clear mind, poor spirit, reduced diet, poor sleep, dark stools, no abnormal urine, and a weight loss of 5 kg.

The patient is generally healthy, without history of hypertension, diabetes, coronary heart disease, tuberculosis, hepatitis, history of major surgery, trauma, history of blood transfusion and blood donation, history of drug and food allergy, and history of vaccination varies with the local area.

Body temperature: 36.
3℃, pulse: 102 beats/min, breathing: 20 beats/min, blood pressure: 108/59mmHg.

Physical examination: clear mind, poor spirits, anemia, clear breath sounds in both lungs, no dry and wet rales, heart rhythm, no pathological murmurs in the auscultation area of ​​the heart valves, soft abdomen, tenderness of the whole abdomen, no Abnormal masses were touched, no rebound pain, normal bowel sounds, and no edema in both lower limbs.

The results of the five classification of blood routine (2021-02-16): white blood cells (13.
15×109/L); percentage of neutrophils (75.
9%); neutrophils (10×109/L); red blood cells (1.
99×1012/ L); Hemoglobin (45g/L); Platelets (587×109/L); ▎Preliminary diagnosis: 1.
Abdominal pain to be checked; 2.
Gastrointestinal bleeding; 3.
Severe anemia.

This patient has a clear diagnosis of gastrointestinal bleeding, low hemoglobin, anemia, gastroscopy, colonoscopy, and capsule endoscopy for normal procedures.
However, this patient has severe anemia, and gastroscopy is not suitable for the time being.
In addition, the patient’s abdominal pain will not cause digestion.
Ulcer combined with perforation, right? Let's do imaging tests first.

CT examination of the abdomen was performed on the day of admission, and blood transfusion was given.

CT examination of the abdomen is to consider: 1.
Small intestine occupancy with small intussusception; 2.
Liver cyst, right kidney atrophy; 3.
Prostatic calcification; 4.
Nodules on the lower edge of the left adrenal gland, enlarged lymph nodes? The cause of the bleeding was considered to be a small intestine tumor.
The surgeon was asked to consult and was transferred to the gastrointestinal hepatobiliary surgery, and surgery was performed on February 17.

Surgical process: 15cm from the ligament of Qu’s small intussusception and dilatation of the intestinal tube; a median incision in the middle abdomen is taken about 8cm long, and the skin and subcutaneous layers are cut into the abdomen in turn.

The intussusception of the intestinal tube is proposed, and the intussusception of the small intestine is returned.
The small bowel tumor is 15cm away from the ligament of flexus, and the diameter is 4cm.
The corresponding mesentery is cut along the pre-resected intestine tube to completely stop the bleeding, and the intestinal tube is cut about 10cm.

The postoperative pathological result was a small bowel malignant tumor, which was considered poorly differentiated adenocarcinoma; the size of the tumor was 4.
5cm×3.
5cm×3.
5cm, and the tumor tissue invaded the deep muscle layer of the intestinal wall; no clear nerve invasion and intravascular tumor thrombus were seen; both sides were cut No tumor was seen at the end; a non-neoplastic lesion was seen between the surrounding intestinal wall.
Considering the ectopic pancreatic tissue with ductal hyperplasia.

In view of the malignant tumor, the enhanced CT examination of the abdomen showed: 1.
Postoperative changes of small bowel space, flat intestinal gas, pelvic fluid, and pneumoperitoneum; 2.
Abnormal enhancement of liver and spleen, nodules in the left adrenal gland , Consider multiple metastases; 3.
Liver cysts, right kidney atrophy.

Diagnosis of small bowel adenocarcinoma with multiple metastases, please consult an oncologist, and recommend elective chemotherapy.

The patient did not bleed again and was discharged from the hospital.

Recognizing primary small bowel tumors Primary small bowel tumors are relatively rare tumors of the digestive tract.
Because of their atypical symptoms, most small bowel tumors are difficult to detect early, so early diagnosis is difficult.

Clinical manifestations: abdominal pain, abdominal mass, gastrointestinal bleeding, intestinal obstruction and jaundice.

Abdominal pain is the most common symptom.

Be vigilant in the following situations: 1.
Unexplained periumbilical or right lower abdominal pain, which aggravates after eating and relieves after defecation; 2.
Adult intussusception; 3.
Intermittent black stool, blood in the stool or diarrhea, no gastroscopy and colonoscopy See abnormal; 4.
Unexplained intestinal obstruction; examinations include: enterography, abdominal color Doppler ultrasound, CT or magnetic resonance.

Small bowel tumors can be derived from two parts, epithelial and non-epithelial, and the pathological types are very complicated.
There are more than 40 known pathological types.

Small bowel malignant tumors account for 3/4 of all small bowel tumors.

So far, surgery is still the only recognized effective treatment for primary small bowel tumors.

Lessons learned: 1.
Patients who encounter gastrointestinal bleeding usually have gastroscopy, colonoscopy, and capsule endoscopy.
However, if the patient does this, the time will be delayed and the capsule endoscopy may not be able to pass the lesion.

It is necessary to do a CT examination of the abdomen in time.

2.
Small bowel tumors are rarely encountered in clinical practice.
If they are encountered, surgery is the first choice.

3.
If CT suggests space-occupying lesions, if conditions permit, it is better to do enhanced CT.

References: [1] Jiang Guoping, Yu Jun, Yu Jiren, etc.
, diagnosis of primary small bowel tumors.

Journal of Practical Oncology, 2000, 15: 203-204.
[2] Li Ping, Diagnosis of smooth muscle tumors of the small intestine, Chinese Journal of Surgery, 1989.
27: 394-395.