Read the following case study and answer the questions that follow. Submit your answers to this Dropbox.
Chief Complaint: 62-year-old man with esophageal bleeding
History: Vincent Miller, a 62-year-old accountant, has had a “drinking problem” throughout most of his adult life. He drinks about a half-case of beer each day. He has lost several jobs over the years for drinking at the workplace or showing up for work drunk. He lost his driver’s license for drunk-driving, and his drinking has placed a considerable strain on his marriage. He has tried several self-help programs as well as Alcoholic’s Anonymous, all with little success. He has been hospitalized on several occasions over the years. Vincent has a severe tremor in his hands (probably a result of excessive alcohol intake), which makes it very difficult for him to use a spoon, fork, and knife to eat. It’s your first day on the job as an occupational therapist, and you are consulted by his physician to see if there is any way to help Vincent use eating utensils. Not knowing anything about him, you open up his past medical records, which, incidentally, are quite thick.
First Hospitalization:
You note that Vincent was hospitalized at age 32 with a complaint of vomiting up blood after a drinking binge that lasted seven days and was marked by excessive and repeated vomiting episodes. The vomitus was bright red.
The hospital chart lists a diagnosis of “Upper GI bleed” due to a Mallory-Weiss tear. You look up “Mallory-Weiss tear” in an internal medicine textbook and see that it is defined as “a longitudinal tear in the mucosa at the gastroesophageal junction — i.e. in the area of the lower esophageal sphincter — caused by repeated vomiting.”
Questions:
- Why was the blood bright red, rather than the color of “coffee grounds”?
- Based upon your knowledge of the vomiting reflex, why might severe vomiting tear the mucosa?
Second Hospitalization
At age 36, Vincent was hospitalized again, this time with complaints of abdominal pain in the upper epigastric region (i.e. just below the xiphoid process of the sternum) and “coffee-grounds” emesis. He also complained of “heartburn” (a burning sensation in the area of the sternum) which was partially relieved with antacids. A diagnosis of “upper GI bleed due to gastritis and reflux esophagitis” is noted in the chart.
Questions:
- What is causing the pain in the upper epigastric region ? What barrier(s) normally protect the stomach lining from its own acid?
- What is reflux esophagitis?
- Can you think of any treatments for Vincent’s problems?
Expert Solution Preview
Introduction:
This case study involves a 62-year-old man with a history of alcoholism who presents with esophageal bleeding. As an occupational therapist, the task is to provide a solution to help Vincent use eating utensils. In order to understand his condition, we look at his past medical records which reveal his previous hospitalizations. The following questions are based on his medical history.
1. Why was the blood bright red, rather than the color of “coffee grounds”?
The bright red color of the blood indicates that the bleeding was from the upper gastrointestinal tract, most likely from the area around the gastroesophageal junction where the tear occurred. The dark, “coffee grounds” color of vomit is indicative of blood that has been partially digested in the stomach, and is a sign of lower gastrointestinal bleeding.
2. Based upon your knowledge of the vomiting reflex, why might severe vomiting tear the mucosa?
Severe and repeated vomiting can cause a significant increase in intragastric pressure, leading to a Mallory-Weiss tear in the mucosa. The tear is caused by the shearing forces generated by the contraction of the diaphragm and abdominal muscles during vomiting.
3. What is causing the pain in the upper epigastric region? What barrier(s) normally protect the stomach lining from its own acid?
The pain in the upper epigastric region is likely caused by the inflammation of the stomach lining due to gastritis. The barrier that normally protects the stomach lining from its own acid is a layer of mucus secreted by the gastric glands.
4. What is reflux esophagitis?
Reflux esophagitis is a condition where there is inflammation of the esophagus due to the contents of the stomach backing up into the esophagus. This can be caused by a weak lower esophageal sphincter, a hiatal hernia, or abnormal esophageal contractions.
5. Can you think of any treatments for Vincent’s problems?
Treatment for Vincent’s problems would involve addressing his alcoholism through counseling and rehabilitation, as well as medication to alleviate his gastritis and reflux esophagitis symptoms. He may also require endoscopy or surgery to repair any damage to the gastrointestinal tract. Occupational therapy can aid in helping Vincent find ways to perform daily tasks such as eating.
