Abstract
Introduction
Gastrointestinal bleeding is the most common complication occurring in up to ten percent of patients. Surgical involvement is sometimes necessary in such cases. There are only a limited number of published reports on the use of corticosteroids for the treatment of intestinal bleeding. 1 We share our experience of using dexamethasone in the treatment of a massive haemorrhagic complication in a young adult with enteric fever.
Case history
A 21-year-old man was admitted to the Dicle University Hospital, with a 20-day fever, frontal headache, abdominal discomfort, abdominal distention, nauchy and meleana. The fever had been mild and irregular at first and followed a chilling period. He had weakness and fatigue. Three days earlier he had been prescribed oral ampicillin/sulbactam and acetaminophen. His condition was severe when he was admitted to Dicle University Hospital.
The physical examination revealed confusion, widespread tenderness, abdominal distention and hepatosplenomegalia. His temperature was 39.2°C; pulse 92 beats/min; respiration 22/min; and blood pressure 90/60 mmHg. An examination showed a slight rectal bleeding. The occult blood test of stool was strongly positive.
The leukocyte count was 2200/mm3, platelet 46,000/mm3, haemoglobin 10.2 g/dL and prothrombin time 14.0 s. Surgery was considered for the abdominal distention and because of the liquid and air levels shown by abdominal radiography. Oral feeding was stopped. Antiemetic, antiacid and ciprofloxacin 800 mg/day (two doses of 400 mg) were started via intravenous. Salmonella typhi was isolated from the stool and blood cultures. The strain was resistant to chloramphenicol, ciprofloxacin and sulbactam/ampicillin.
He was monitored for intestinal bleeding. The fever decreased to a normal level on the third day, but intestinal bleeding gradually became massive and the patient became hypotensive. In the third day, his hepatoma cell count (Htc) was 24% and he was supported with a blood transfusion. In the fifth day, dexamethasone treatment was started at 3 mg/kg/day, diluted with 100 mL 0.9% NaCl solution/hour. It was decreased step by step and given as 2 mg/kg/day on the second day, 1 mg/kg/day on the third day and 0.5 mg/kg/day on the fourth day. The bleeding stopped dramatically on the second day of the patient being given dexamethasone. He became stabile and there was no abdominal distention or discomfort. He began oral feeding. On the 12th day, Htc was 32.8%, haemoglobin 11 g/dL, white blood count 4700 mm3, C-reactive protein 3.2 mg/dL and other biochemical parameters were normal. Ciprofloxacin treatment ended on the 10th day and he was discharged with a healthy situation. Ten days later he was healthy and suffered no side effects from the dexamethasone.
Discussion
This case presented with a severe intestinal bleeding. The management of gastrointestinal bleeding complicating typhoid fever is usually conservative, although massive bleeding may, at times, require surgery. 2 The empiric antimicrobial therapy for intestinal bleeding is using an effective antibiotic and supporting the patient. 3
There is only a limited amount of material found in the medical literature about the use of corticosteroids in the treatment of massive intestinal bleeding. Hoffman et al. showed the effectiveness of high-dose dexamethasone treatment in the prevention of death in severe typhoid fever cases. 4 In our case, the dose of dexamethasone given was based on that suggested in a study by Hoffman. Our experience supported that, in serious cases, corticosteroid use is one of the acceptable treatment choices for massive intestinal bleeding. Treatment with dexamethasone should be considered in severe intestinal bleeding cases before the decision to perform surgery is taken.