Hemoptysis patient, due to GI bleeding, ddx with lung lesion WARNING !! LOTS OF CT REPORT !!

1. Case
Presentation
內科intern吳易儒

2. Basic data
Name: 廖OO
Age: 47y/o
Gender: Male
Admission: 6.17/2014
Education: Junior high school
Occupation:包工程水電行
Chart number: 41840334

3. Chief complaint
Hemoptysis for 2 days

4. Present illness
● This 47 y/o male with history of liver
cirrhosis and HBV infection was admitted to
our ER due to hemoptysis for 2 days.
● As the statement of him, he has followed
up his liver disease in our OPD. But he lost
followed up since 2011.

5. ● Half a year ago, he would have been
choked sometimes while drinking water.
Bleeding after taking food and dysphagia
were mentioned, too.
● About 2 weeks ago, a left submandibular
mass was noted by him. Also, he
complained about tarry stool.

6. Present illness
● nausea(-)
● vomiting (-)
● dizziness (-)
● nosebleed(-)
● dyspnea(-)
● chest tightness(-)
● fever(-)
● cold sweating(-)
● abdominal pain(-)
● cough(-)
● dysuria(-)
● anti-coagulant use
(-)
● He suffered from hemoptysis since 2 days
ago. Therefore, he went to our ER.

7. Past medical history
Hospitalization:
2010.3.3 -3.15
2011.5.6 -5.14
2011.8.27 -9.5
GI bleeding
-> Esophageal Varices s/p EVL

8. Personal history
Allergy: none
Alcohol: heavy drinkiner(維士比)
Betal nut: yes
Cigarette: 0.5ppd for 20 years
Travel history: denied
Family history: Father had DM type II

9. Physical examination
GCS: E4M6V5
T/P/R: 37.7/104/25
BP: 101/68
HEENT
Eyes-Conjunctiva: pale
-Cornea：yellow
Neck-General：left neck big mass

10. Physical examination
-Carotid pulses：regular , normal amplitude,
no bruits.
-Jugular vein：no engorgement
Chest and Lungs
-Inspection：normal thoracic cage, normal
expansion, no spider nevi.
-Palpation：equal tactile fremitus.
-Percussion：resonance to both lung field
-Auscultation：clear

11. Physical examination
Heart
-Inspection/palpation：PMI over the L't 5th
ICS mid-clavicular line, no LV heaves.
-Auscultation：regular rhythm, normal S1,
loud S2, no S3, S4 or opening snap.
Abdomen
-Inspection：no scars,no spider nevi, RUQ
superficial vein engorgement.

12. Physical examination
-Auscultation：normoactive bowel sounds ,
no bruits.
-Percussion：no shifting dullness . tympanic
percussion
-Palpation：no tenderness ,no Murphy's sign,
soft, no muscle guarding,no rebound
tenderness, no mass.no hepatomegaly ,no
splenomegaly

13. Hospital course-ER
Glucose
AC
AST PT INR aPTT
109 79 12.8 1.22 28.8
Hb HT WBC Seg
Lympho
cyte
9.0 27.4 3.4 79 13
BUN
10
Creatini
ne
0.6

15. ENT consultation 6/16 12:22
ENT finding:
Lt neck level II mass 2x2 cm, firm, non-movable
Lt parapharyngeal wall tumor with ulceration, no active bleeding
A: oropharyngeal tumor
r/o EV or GI bleeding
Liver cirrhosis
P: please trerat medical problem as your expertise
1. arrange PES
2. arrange neck CT or MRI with /without contrast including
hypopharynx
3. ENT OPD f/u for further evaluation

32. CT report
● Evidence of bulky tumor involving left
lateral oropharyngeal, hypopharyngeal and
laryngeal walls. The origin is hard to
defined.
● Enlarged lymph nodes are noted at
submental area, left lateral retrophryngeal
space and along left internal jugular chain,
level II

33. Gastroscopy 2014/06/16 14:36:42
● Active bleeding in the left epiglottis.
● Suggest ENT for hemostasis and intubation
as needed for high risk of suffocation.

35. Laryngeal scope 2014/06/16 18:08:
55
Left hypopharyngeal ca with ulceration and
blood clot, no active bleeding
Left vocal palsy
Airway compromise
【Diagnosis】
Left hypopharyngeal ca
Suspected GI bleeding
【Comment】
Protect airway
Embolization if needed

38. Hospital course-ER ABG 60% PEEP 5
pH PaCO2 PaO2
7.553 28.3 178.8
SaO2
99.4%
HCO3 BE
24.3 3.1

39. Tentative diagnosis
● •Suspect left hypophargeal cancer with
ulceration and active bleeding s/p
endotracheal intubation for protect
airway
● Anemia, related tumor bleeding
● EV s/p ligation without active bleeding
● Liver cirrhosis, child A
● History of gastric ulcer

40. MICU Hospital course
● NG irrigation
● Blood transfusion on 6/17
-> Hb rise from 7.7 to 9.7
● NPO
● CVP for nutrition

41. Hb
6/16
12:01
6/17
00:23
6/17
09:06
6/17
13:21
9.0 7.7 9.4 9.7
6/17
17:49
6/18
09:47
6/18
14:32
6/19
10:58
8.9 8.5 9.0 9.4

42. Gastroscopy 6/17 21:23pm
ESOPHAGUS
1.One protruding mass with blood coating and friable
mucosal change at the left side of epiglottis are noted.
Mild oozing is found. One pseudo-tract is noted below the
right side of pyriform sinus (located upper of the
esophageal opening).
2.Two varices (2F1, Cb, Li, RCS(-)) and one fibrotic
ring are noted at the EC junction.
STOMACH
1.Superficial Gastritis
2.Ulcer

43. Hb
6/16
12:01
6/17
00:23
6/17
09:06
6/17
13:21
9.0 7.7 9.4 9.7
6/17
17:49
6/18
09:47
6/18
14:32
6/19
10:58
8.9 8.5 9.0 9.4

44. HT Albumin
Total
Bilirubin
Direct
Bilirubin
AST
29.3 2.7 2.7 1.0 72
Ammonia
Glucose
AC
K P Ca Mg
131 120 3.3 1.6 7.7 1.3

45. MICU Hospital course
Chest echo: Left lung consolidation
Fever up to 38.2 degree
Blood culture: GPC
Arrange tracheotomy and biopsy to evaluate
the neck mass

48. Medicine
● Esomeprazole for peptic ulcer
● Glypressin for suspect GI bleeding
● Metoclopramide for GI bleeding
● Silymarin for liver cirrhosis
● 6/18 T-piece
● 6/20 transfer to general ward.

49. Discussion

50. Neck mass

51. History taking
AGE
Pediatric(16-40)-inflammatory or congenital
Adult(>40)-neoplastic(tobacco/alcohol)
GROWTH PATTERN
Duration-longer better
Rapidly-infection/lymphoma
Fluctuate-viral/URI infection/congenital
SYMPTOMS
Cervical meta-pain/hoarseness/dysphagia/otalgia
OTHER fever/BW loss/TOCC

52. Location

53. Physical examination
● Characteristics
location, size, shape, consistency, tenderness, mobility,
and color
● Oral Mucosa
● Ear
● Oropharyngeal
● Skin
● Cranial nerve
● Thyroid gland
● Abdomen

54. Labtory studies
● Most
CBC
Infection/Inflammation
ESR, CRP, Blood culture, EBV/CMV(adenopathy)
Specific serlogy
T gondii, Bartonella, Tularemia, TB skin test
Bone marrow biopsy
hematologic malignancy

55. Image study
● Ultrasound
guide fine needle aspiration
● CT
indentify primary source
possible vascular origin
● MRI
soft tissue tissue
perineural/CNS
● PET
detect distant metastasis
not sensitive in neck mass

56. Diagnostic studies
● Fine needle aspiration(FNA)
Cytology, Virus(EBV/HPV)
● Core biopsy
Ultrasound-guided/CT guided
● Excisional/incisional biopsy
Frozen section analysis

58. Thanks for your attention

59. Hemoptysis

61. Airway obstruction