A 77-year-old man was referred to the hospital emergency department from his health centre for assessment of haematemesis. The patient's personal history included high gastrointestinal bleeding two years earlier, in the context of taking aspirin due to a catarrhal process, as well as repeated renoureteral crises (CRU) and asthma. No further information was available at the time regarding his personal history. He was taking anti-inflammatory-bronchodilator inhalation treatment; of his own volition the patient had recently discontinued his usual treatment with omeprazole. Diagnosed three days before with CRU at his health centre for colicky low back pain radiating to the left lower quadrant (LQ), he had received intramuscular diclofenac and aspirin on demand, with partial relief. On presentation of haematemesis, he was referred for assessment.
In the emergency department, the patient reported, in addition to this radiating lumbar pain, which he recognised as having similar characteristics to previous CRU, the presentation in the last eight hours of heartburn, as well as trembling when getting out of bed and instability, which had led to a fall and nasal trauma. He had also presented three vomits of bloody content during this period. Physical examination revealed good general condition, BP 70/50 mm Hg with normal capillary refill, HR 90 bpm, tachycardia 36º C; nauseous, with pallor concomitant with nausea, but basically normal colour; wound in nasal bridge with traces of bleeding in nostrils and "coffee grounds" in labial commissures; abdomen painful to deep palpation in CII, with no signs of peritoneal irritation or apparent masses and negative rectal examination for blood and melena. Samples were taken for laboratory and cross-matching tests and serum therapy was started via two peripheral venous lines, which managed to raise the blood pressure without normalising it. Blood tests showed Hb, 12.9 g/dL, Ht. 36.1%, leukocytes 27,500/µL with 87% neutrophils, platelets and coagulation normal; urea 52 mg/dL, creatinine 2.86 g/dL; the rest normal. Given this situation of haemodynamic instability and haematemesis in a patient with a history of upper gastrointestinal bleeding and current treatment with potentially gastrolesive drugs, an urgent endoscopy was requested.
Immediate endoscopy revealed an oesophagus with clearly ischaemic mucosa from 30 cm and necrotic up to 38 cm, as well as a normal fundus, gastric body, incisura and antrum, with some minimal haematic debris. During endoscopy the patient went into cardiorespiratory arrest due to pulseless electrical activity. Resuscitation manoeuvres were unsuccessful and the patient died. Necropsy revealed acute necrotising erosive oesophagitis in the distal 14 cm and aortic arteriosclerosis, predominantly abdominal and iliac bifurcation, with saccular aneurysm in the abdominal aorta 13 cm long and 8 cm in diameter ruptured, massive retroperitoneal haemorrhage of approximately 3,000 cc and extension to the peritoneal cavity.