Critical management of upper gastrointestinal bleed with septic shock in an elderly patient

Kiruthiga1, Jenma Rakkini2, Subadhra Devi3, Mahalakshmi4

1Neuro ICU Nurse, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

2Nursing Supervisor, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

3Nurse Educator, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

4Nursing Superintendent, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

Abstract

Upper gastrointestinal tract (GI) bleeding is a life-threatening condition, often presenting with hematemesis or melena. Prompt diagnosis and treatment are crucial to prevent complications and improve patient outcomes.

Background

Upper GI bleeding is a common medical emergency with considerable morbidity and mortality. Common causes include peptic ulcers, esophageal varices, Mallory-Weiss tears, and gastric erosions. Risk factors include Helicobacter pylori infection, NSAID use, alcohol intake, and liver disease. Management requires stabilizing the patient, controlling the source of bleeding, and treating underlying causes. Early endoscopy is essential, and successful outcomes require a multidisciplinary approach.

Case Presentation

A 70-year- aged male with a history of systemic hypertension and old CVA (left MCA infarct) for which he had undergone a left FTP decompressive craniotomy on 24/02/2016.

After a domestic fall, he was diagnosed with cervical spondylosis and quadriplegia, and underwent anterior cervical discectomy with cage stabilization and tracheostomy on 14/02/2025.

He was readmitted with,

  • Two episodes of seizures
  • Bleeding from tracheostomy site
  • One episode of hematochezia

Initial Investigations

  • Endoscopy: Hiatal hernia, duodenal ulcer (Forrest II A), Rapid Urease Test (RUT) positive
  • Hemoclips applied for hemostasis
  • Repeat episodes of melena and hemoglobin drop → repeat endoscopy and hemoclipping
  • Continued bleeding → Emergency laparotomy with duodenotomy and gastrojejunostomy

Postoperative Course

  • Developed septic shock requiring:
    1. Mechanical ventilation
    2. IV fluids
    3. Inotropic support (Inj. Noradrenaline)
    4. Broad-spectrum antibiotics
  • Respiratory status improved
  • Enteral nutrition via NG tube
  • Successfully weaned to tracheostomy collar
  • No recurrent GI bleeding

Despite initial guarded prognosis (DNE), the patient improved significantly with coordinated multidisciplinary care.

Social History

Non-smoker, no alcohol use

Allergies

No known drug or environmental allergies

Past Medical History

  • Type 2 Diabetes Mellitus
  • Old CVA – Right hemiplegia (2016)
  • Aspiration pneumonia (2016)
  • Systemic hypertension (2016)
  • Acute gastroenteritis (2021)
  • Cervical injury due to fall (2025)
  • Left MCA/lacunar infarct (2025)
  • C3–C4 disc bulge with quadriplegia (2025)

Past Surgical History

  • FTP decompressive craniotomy with duraplasty (2016)
  • Anterior cervical discectomy with cage stabilization and tracheostomy (2025)

Physical Examination:

  • Vitals: Temp 98.6°F, HR 84 bpm, RR 20/min, BP 100/70 mmHg, SpO₂ 97% (T-piece @ 6L)
  • Airway: Tracheostomy secured
  • Neuro: GCS E4 VT M6, obeying commands
  • CVS/RS: Stable
  • Abdomen: Soft, non-distended

Investigations Summary

InvestigationResults
Alanine Aminotransferase (ALT/SGPT)21.8 U/L
Calcium Serum7.6 mg/dL
Creatinine4.10 mg/dL
Gamma - Glutamyl Transferase (GGT)122 U/L
Globulin2.52 g/dl
Glucose193 mg/dL
Indirect Bilirubin0.75 mg/dL
K +6.5 mmol/L
Magnesium1.91 mg/dL
Phosphorous3.6 mg/dL
Potassium6.1 mmol/L
Sodium132 mmol/L
Total Protein5.38 g/dl
Urea Serum184.04 mg/dL
Control (PT)11.3 Seconds
Haematocrit32 %
Haemoglobin8.6 g/dl
Packed Cell Volume (PCV)30.7 %
Platelet Count263000 cells/µl
Test (PT)31.2 Seconds
Total RBC Count3.37 10^9/cmm
INR2.79
CA++(7.4)0.95 mmol/L
Total Bilirubin2.83 mg/dL
  • Initial Hb: 8.2 → monitored Q12H
  • CRP: 130.29 → improved to 22.99 mg/L
  • Electrolytes: Hypokalemia, low magnesium/phosphorus → corrected

Imaging

  • USG: Hepatomegaly, fatty liver, bilateral mild pleural effusion
  • Chest X-ray: Suspected pleural effusion
  • Doppler: Left IJV DVT, cellulitis

Endoscopy Findings

  • Hiatal hernia
  • Duodenal ulcer, Forrest II A
  • RUT positive
  • Hemoclipping successful initially

Management

Medical

  • IV fluids, PPIs
  • Injection therapy (e.g., adrenaline)
  • Hemoclips × 3
  • Empirical antibiotics
  • Anticonvulsants prescribed
  • Electrolyte correction
  • Tracheostomy weaning

Surgical

  • Emergency laparotomy, duodenotomy, and gastrojejunostomy
    1. Duodenum opened longitudinally
    2. Bleeding vessel ligated
    3. Ryle’s tubes placed
    4. Duodenum sutured closed

Dietary Management

  • Initially NPO followed by IV fluids
  • Started on clear liquids via NJ tube (30–75 ml/hr)
  • Advanced to nasogastric feeding every 2 hrs
  • Kitchen feed + Ensure Plus (200 ml/hr)

Hospital Course Summary

  • Initial GI bleed managed with hemoclips
  • For Rebleed surgery was performed
  • Managed septic shock and respiratory failure in ICU
  • Weaned to tracheostomy collar
  • No further bleeding
  • Stabilized and planned for follow-up

Final Diagnosis

  1. Upper GI bleeding with deep duodenal ulcer (Forrest II A)
  2. Post-op duodenotomy and gastrojejunostomy
  3. C3–C4 disc bulge with quadriplegia

Nursing Care

Preoperative

  • Monitor vitals
  • Lab evaluation
  • IV access and fluid management
  • Blood crossmatch and transfusion
  • Educate patient/family

Postoperative

  • Monitor signs of re-bleeding
  • Check for melena, hematemesis, hematochezia
  • Continue IV fluids, PPIs, transfusions as ordered
  • Jejunal feeding → NG feeding
  • Maintain airway/tracheostomy care
  • Multidisciplinary coordination

Infection Prevention

  • CLABSI, VAP, CAUTI precautions
  • Daily wound dressing
  • Blood sugar and fluid monitoring
  • Pressure sore prevention
  • Use of music therapy and communication aids

Discharge Medications

Drug NameDose
Inj. Levetiracetam1 gm
Tab. Lacosamide100 mg
Tab. Esomeprazole40 mg
Inj. Enoxaparin40 mg
Heparin lock flush2 ml
Tab. Lycopene1 cap
Tab. Paracetamol650 mg
Neb. Levosalbutamol + Ipratropium1 respule

Conclusion

Upper gastrointestinal bleeding is a potentially life-threatening emergency. Timely intervention, surgical support, and coordinated ICU and nursing care significantly improve outcomes. This case demonstrates the critical role of multidisciplinary care and comprehensive nursing management in stabilizing complex geriatric patient with multiple comorbidities and improving their quality of life.

 

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