Massive Esophageal Bleeding in an Immunocompetent Young Man

Abstract

A 21-year-old man presented with hematemesis and melena. On examination, vital signs were stable with temperature of 37.1°C, blood pressure of 120/80 mmHg, and pulse rate of 72 bpm. His past and family histories were nonspecific except for taking cough remedies on account of mild coughing for 2 months. Laboratory investigation revealed a white blood cell count of 6.7 × 10 3 /mL, hemoglobin level of 12 g/dL, and normal blood chemistry. HIV screening test was negative. Emergent endoscopy revealed a longitudinal esophageal ulcer at 30 cm from the incisors. On the ulcer base, a blood clot was attached, but no active bleeding ( Figure A ). To identify the adjacent structures around the esophageal ulcer, computed tomography (CT) of the chest was performed and it showed multiple centrilobular nodules in the apicoposterior and lingular segments of the left lung ( Figure B ). Also, the mediastinal lymph nodes were filled with necrotic densities and the delineation between the necrotic mediastinal nodes and the adjacent mediastinal structures was not clear ( Figure C ). Air densities in the lymph nodes, in conjunction with the esophageal ulcer at endoscopy, suggested a possibility that there was a connection between the mediastinal lymph nodes and esophagus. Because active bleeding had not been found at the initial endoscopy and his vital was stable, the patient had been on intravenous proton pump inhibitor without oral intake. Two days later, massive hematemesis occurred with hemodynamic instability; blood pressure of 80/60 mmHg and pulse rate of 150 bpm