An Intriguing Case of Gastrointestinal Bleeding

Abstract

Case Report: A 32-year-old woman with a history of a fatty abdominal tumor resected in childhood was referred to us for melena and anemia. She had a history of duodenal ulcer in 2007 while on NSAIDs for back pain. Subsequently developed gastric perforation and underwent surgical repair with a Graham patch. She continued to have melena and anemia requiring transfusions every 1-2 months. She remained on PPI and denied the use of NSAIDs. Between 2007 and 2008 she underwent several endoscopic procedures that revealed gastric ulcers. She underwent a partial gastrectomy, truncal vagotomy, Roux-en-Y gastrojejunostomy with celiac block in 2008 due to recurrent overt bleeding. However she still continued to bleed and required blood transfusions every 1-2 months. Gastrin, secretin stimulation and basal acid output were normal. Repeat enteroscopy with wide variety of hemostasis techniques failed to control bleeding that was seen primarily within the proximal Roux limb and at the site of the jejunojejunostomy. Small bowel biopsies showed increased intraepithelial lymphocytes and villous blunting. She was tried on a gluten free diet for possible celiac disease with no resolution of symptoms. She developed severe malnutrition and protein losing enteropathy. Between 2007 and 2011 she had been seen at several other institutions by several different providers. Intraoperative endoscopy in July 2011 showed normal jejunojejunostomy but significant inflammation, ulceration and punctuate bleeding within the roux limb and giant gastric body ulcer. Total gastrectomy with Roux-en-Y esophago-jejunostomy and feeding jejunostomy was performed. Resected specimens showed nonspecific inflammatory changes but this was not consistent with either sprue or refractory sprue, ischemia, vasculitis, autoimmune enteropathy, or IBD. She continued to be symptomatic. We were convinced that she had an autoimmune process causing recurrent ulcerations and started her on prednisone with no benefit. Remicaide was started in October 2011. She was sent to another institution where in addition to repeating all the above procedures she tested positive for NSAIDs and aspirin. When confronted, the patient admitted that she had been using NSAIDs, although she had repeatedly always denied it. It was clear then that the patient had been using NSAIDs all along and her recurrent ulcers were from surreptitious NSAID use. She is currently awaiting psychiatric evaluation. Conclusion: Factitious disorders are underdiagnosed because hospital personnel often fail to spot the deceptions that are characteristic of this disorder. Although she was evaluated at several institutions by multiple providers, this diagnosis was not entertained.