S3455 Non-Survivable GI Bleed in a Patient on Chronic Steroid Therapy

Abstract

INTRODUCTION: Steroid therapy has been established as a risk factor for peptic ulcer disease. (1) Chronic corticosteroid therapy also suppresses the hypothalamic pituitary adrenal (HPA) axis. We present a case of rapid deterioration of a patient who developed a GI bleed (GIB) on chronic steroid therapy. CASE DESCRIPTION/METHODS: A 68 year-old African-American male with a past medical history of a CVA with residual left-sided weakness and dysarthria, HTN, spinal stenosis and hemolytic anemia presented with dysarthria and right-sided weakness. Due to his autoimmune hemolytic anemia, months prior, he was started on a 1mg/kg dose of prednisone with plans for a long taper (65mg daily). He had been admitted to inpatient rehabilitation after undergoing laminectomy when a rapid response was called due to hypotension. No GIB was reported by bedside nursing, and his pressure normalized initially after IV fluid boluses. Another rapid response was called shortly afterwards, again for hypotension, and the patient was transferred to the general medicine wards. An episode of hematemesis was reported. His hemoglobin was 7.6 mg/dL from his baseline of 9.8. He was transfused 1 unit of pRBCs, and GI was consulted for presumed UGIB. DAPT and prednisone were discontinued and IV PPI was initiated. Upon arrival to general medicine wards, he was profoundly hypotensive and was immediately transferred to the ICU on pressors. In the ICU he was intubated for airway protection. Prior to attempting an EGD, he developed monomorphic V tach, and the procedure was aborted. Now on amiodarone, he continued to require increasing vasopressors. He received 12 units of whole blood, 6 units pRBCs, 1 pool platelets, and 2 units FFP. Despite the large volume resuscitation efforts and vasopressors, the patient remained hypotensive with minimal overt GI bleeding. Massive upper GI bleed with perforation and intra-peritoneal bleeding was suspected. Shortly after, the patient expired. Post-mortem examination showed minimal blood in the GI tract and limited blood in the peritoneal cavity without significant lesion or ulceration of the GI tract. The cause of death was listed as hemorrhagic shock. DISCUSSION: Along with added risk of GIB, corticosteroids cause relative adrenal insufficiency. Stress dose replacement therapy should be considered in hypotensive patients even with suspected GI bleeding.