Diagnostic Dilemma

Hematemesis with hypotension

A 2-year-old girl presented with a small amount of blood in vomit 3 hours ago. There was no abdominal pain, retching, black stools, jaundice, or any drug ingestion. On examination, she had a pulse of 100/min with a blood pressure of 90/68 mm of Hg. She had hepatomegaly without splenomegaly. Other systems were normal. Investigations showed:
• Hemoglobin = 11.4 gm/dl
• WBC count = 11,100/cumm [41% polymorphs, 56% lymphocytes]
• Platelet count = 2,65,000/cumm
• Prothrombin Time = 12.2 seconds (Normal)
• Partial thromboplastin time (PTT) = 35.3 seconds (Normal).

A few hours later she developed an erythematous maculopapular rash. She was treated with IV Fluids but continued to have intermittent hypotension.

What is the cause of hematemesis?
Expert Opinion :
The common causes of hematemesis are:
• Gastritis
• Portal hypertension
• Coagulopathy
• Mallory Weiss syndrome
• Arterio-venous malformation

Gastritis usually has abdominal epigastric pain and there would be coffee-colored vomitus due to the action of gastric acid on the blood. There would also be precipitating causes such as ingestion of NSAIDs or other drugs. With portal hypertension, splenomegaly may be present. Mallory Weiss syndrome occurs due to esophageal tear following prolonged vomiting and retching. The arteriovenous malformation can cause hematemesis but as the bleeding may be severe, there may be black tarry stools. However, it does not usually cause hypotension that does not respond to volume replacement even when the child is not having hematemesis.
In this child, hypotension seems to be persistent even after fluid resuscitation and continues to be present even when hematemesis has stopped. Since the child has a rash, hypotension, and one episode of bleeding, one must consider viral hemorrhagic fever (even if the child has no fever) as the cause. In this child, dengue NS1 was positive and she responded to just fluid support.
Answer Discussion :
Charles Horton,Jr
Viral hepatitis
1 month ago
Ali Ali
HSP. rash
2 months ago

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