A 27-year-old male occasional drinker with a history of upper gastrointestinal bleeding (UGIB) due to bleeding ulcus secondary to non-steroidal anti-inflammatory drugs (NSAIDs) for three years.
She was admitted from a hospital in the area to the ICU of our hospital with acute upper gastrointestinal bleeding with hemodynamic involvement.
Upper gastrointestinal endoscopy (UGE) reveals bleeding from the duodenum, placing hemoclips and injecting.
After 24 hours, the patient suffered a syncope with exit of the nasogastric tube (NGT), emergency surgical intervention.
The intervention aimed at UGIB due to bleeding duodenal ulcus penetrating the pancreas, performing longitudinal pylorotomy and ulcer, prior bilateral vagill hemoclips, my hair removal according to helicotomy.
After 24 hours, a drop in hemoglobin of 4 points accompanied by tachycardia occurred, so a new surgical exploration was decided, performing this endoscopy through the pylorus.
When active bleeding is found, the pyloric artery is ligated and a new pyloroplasty with omentoplasty is rebuilt.
Forty-eight hours later, a new drop in hemoglobin, hypotension and tachycardia was observed, which required urgent surgery.
There is a large gastric clot with bleeding point in the posterior aspect of the pylorus, close to the ligation of the pyloric artery, which ceases after the realization of sutures we have performed.
Postoperatively, the patient develops peripancreatic collection draining percutaneous drainage, biliary fistula that is treated conservatively and respiratory distress syndrome from which he recovers.
On the twelfth day after the last surgery, new bleeding with hemodynamic repercussions appeared, requiring urgent surgical intervention.
There is a gallbladder peritonitis perforated by decubitus over the ulcer, ulcer in the first duodenal knee that bleeds profusely.
Antrectomy, resection of the first portion of the duodenum with hemostasis of the ulcer on the pancreas, cholecystectomy and intraoperative cholangiography were performed, which is normal.
Gastrojejunostomy and Roux-en-Y reconstruction were performed.
A week after the last intervention, a duodenopancreatectomy was scheduled, leaving pancreatojejunal and hepatic-jejunal anastomosis tutored.
After this surgery, the patient showed hemodynamic improvement, with definitive control of bleeding episodes.
Postoperatively, she presented septic shock secondary to nosocomial pneumonia treated with broad-spectrum antibiotics, with satisfactory response.
Subsequently, she develops a temporal-spatial disorientation accompanied by ataxia and horizontal nystagmus, as well as weakness predominantly in the left upper limb (SUL), requiring new intubation.
After two unremarkable cranial CT scans, brain magnetic resonance imaging (NMR) was performed, showing changes in signal intensity in the brainstem, especially in the floor of the 4th ventricle, central region of the tubercle.
Treatment with thiamine was initiated with significant improvement of neurological symptoms and improvement of lesions after control for brain MRI.
Shortly after starting treatment, the blood thiamine level is 2 μg/dl (2.0-7.5 μg/dl).
The patient was discharged to the hospital after 60 days of ICU admission, hemodynamically stable, with digestive tolerance and pneumonia in resolution, and was discharged from the hospital 27 days later.
