68M/ UGI bleed, acute GE, AKI s/p CABG

 

Clinical Problem Representation:

A late 60s male with a history of diabetes and CABG on DAPT, presents with acute onset of fever, vomiting, and diarrhea, now complicated by AKI, elevated cardiac markers, and sepsis indicated by high procalcitonin. Imaging shows pulmonary and gastrointestinal involvement with systemic inflammatory response, currently requiring intensive support including mechanical ventilation and vasopressors.

Most Likely Differential Diagnosis:

• Sepsis secondary to gastrointestinal source: The patient's presentation with fever, elevated procalcitonin, and systemic inflammatory response, alongside gastrointestinal symptoms and findings of esophageal ulcers and erosive gastritis on endoscopy, strongly suggest a septic process originating from a gastrointestinal source. The presence of blood in the stomach and duodenum could indicate significant mucosal damage leading to translocation of bacteria.
• Acute gastrointestinal bleeding with hypovolemic shock: The findings of blood in the stomach and duodenum, Forrest class 1b and 3 ulcers, and the patient's hypotension requiring vasopressor support suggest acute gastrointestinal bleeding. This could be causing hypovolemic shock, contributing to his acute kidney injury and metabolic acidosis.
• Acute decompensated heart failure (ADHF): Elevated NT-pro BNP and troponin levels, along with the presence of bilateral pleural effusions and pulmonary opacities on imaging, suggest cardiac involvement possibly due to acute decompensated heart failure, which may be a primary event or secondary to sepsis and volume shifts associated with gastrointestinal bleeding and aggressive fluid resuscitation.

Expanded Differential Diagnosis:

• Acute cholecystitis: The ultrasound findings of cholelithiasis and minimal ascites, along with the patient's abdominal symptoms, raise the possibility of acute cholecystitis, which could be contributing to the septic picture and gastrointestinal symptoms.
• Drug-induced gastrointestinal toxicity: The patient's extensive medication regimen, including the use of NSAIDs as part of his dual antiplatelet therapy, raises the possibility of drug-induced gastrointestinal toxicity leading to ulceration and bleeding.
• Ischemic colitis: Given the patient's cardiovascular history and current circulatory compromise indicated by hypotension and high lactate, ischemic colitis could be a contributing factor to his abdominal symptoms and findings on imaging of sluggish bowel peristalsis.

Can’t Miss Differential Diagnosis:

• Myocardial infarction (MI): The elevated troponin levels, history of CABG, and cardiac symptoms necessitate ruling out acute myocardial infarction, which could be catastrophic if missed and could explain the systemic inflammatory response and multi-organ involvement.
• Mesenteric ischemia: Considering the patient's cardiovascular risk factors, abdominal symptoms, and findings of sluggish bowel peristalsis, mesenteric ischemia must be considered as a life-threatening cause of abdominal pain and systemic inflammation.
• Urosepsis: Given the findings of pus cells and RBCs in the urine, along with the patient's systemic signs of infection, urosepsis could be a contributing factor to his septic presentation and must not be overlooked.

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