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An interval of clinically silent gastrointestinal bleed in dysautonomic spinal cord injury: a case report.
Margo, Theodore E; McMullin, Preston R; Kaddouh, Firas.
  • Margo TE; Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA. teddymargo@me.com.
  • McMullin PR; Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
  • Kaddouh F; Neurosurgery Department, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
BMC Neurol ; 23(1): 70, 2023 Feb 14.
Article in English | MEDLINE | ID: covidwho-2243103
ABSTRACT

BACKGROUND:

Gastrointestinal bleed (GIB) has high incidence in traumatic spinal cord injured (tSCI) patients and can frequently be life-threatening, especially early post-injury. Several risk factors often compound bleeding risk, some are unique to this patient population. Normally, clinical suspicion for GIB arises from symptoms like coffee-ground emesis, hematemesis, melena or even hematochezia. A hemoglobin drop may be a late sign. Due to tSCI, however, patients often experience neurogenic bowels and dysautonomia, which may delay symptom presentation and complicate timely diagnosis of GIB. We report a case of an almost clinically silent GI bleed in the context of acute cervical tSCI. CASE PRESENTATION A 21-year-old female presented with cervical cord transection at C-7 in the setting of motor vehicle rollover, for which surgical decompression was performed. During the acute injury phase, she also received a 10-day course of dexamethasone for symptomatic COVID-19 pneumonia. Two weeks after injury, she underwent percutaneous endoscopic gastrostomy (PEG) placement which demonstrated normal gastric and duodenal anatomy. One week later, a large spike (10x) in blood urea nitrogen creatinine (BUN Cr) ratio raised concern for GIB, but hemoglobin remained stable, and stool color remained unchanged. The following day, a gastroenterology consult was requested under increased suspicion of GIB from a sudden 3.5 g/dL hemoglobin drop. The patient received blood transfusion and pantoprazole. An upper endoscopy was performed, revealing three small duodenal ulcers. Melanotic stool ensued afterwards.

CONCLUSIONS:

Due to dysautonomia, clinical presentation of GIB can be significantly delayed in the tSCI patient population, leaving them vulnerable to succumb to illness. This case illustrates the possibility of an interval in which the patient was bleeding, with the sole indicator being an elevated BUN. Our case calls for closer monitoring of and vigilance for tSCI patients, and possibly employment of different strategies to reduce the incidence and enhance early detection of GIB in tSCI patients to subsequently decrease the morbidity and mortality associated with it.
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Full text: Available Collection: International databases Database: MEDLINE Main subject: Spinal Cord Injuries / Gastrointestinal Diseases / COVID-19 Type of study: Case report / Diagnostic study / Observational study / Prognostic study Topics: Long Covid Limits: Adult / Female / Humans / Young adult Language: English Journal: BMC Neurol Journal subject: Neurology Year: 2023 Document Type: Article Affiliation country: S12883-023-03114-9

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Full text: Available Collection: International databases Database: MEDLINE Main subject: Spinal Cord Injuries / Gastrointestinal Diseases / COVID-19 Type of study: Case report / Diagnostic study / Observational study / Prognostic study Topics: Long Covid Limits: Adult / Female / Humans / Young adult Language: English Journal: BMC Neurol Journal subject: Neurology Year: 2023 Document Type: Article Affiliation country: S12883-023-03114-9