A 60-Year-Old Woman with Gastrointestinal Bleeding in Hemorrhagic Shock: An Unexpected Shift in Shock Etiology

Abstract

This is a case of a 60-year-old woman who presented in hypovolemic shock due to an upper gastrointestinal bleeding. She had a history of chronic alcohol abuse. Standard resuscitation measures with intravenous access and blood transfusions were started. She underwent an upper endoscopy in the operating room under general anesthesia. A bleeding fibrotic lesion in the distal esophagus was found and treated with adrenaline injections and placement of a temporary esophageal stent. After an initial stabilization, she deteriorated in the operating room and developed severe circulatory failure. A bedside echocardiogram was performed and demonstrated severely depressed left ventricular systolic function and mid-ventricular hypokinesia consistent with cardiogenic shock secondary to Takotsubo cardiomyopathy. Instead of further volume resuscitation, treatment efforts pivoted toward inotropic support and afterload reduction with dobutamine and nitroglycerine, respectively. She remained sedated, intubated, and ventilated in the intensive care unit for 4 days and gradually regained left ventricular function. On day 10 left ventricular hypokinesia had subsided and ejection fraction had improved from around 15 to 58%. The case demonstrates the usefulness of echocardiography in phenotyping shock and how it can dramatically change management with improved patient outcome.