still bleeding after successful endoscopic treatment of bleeding ulcer

[scottp]

day 1- 75 yr old father admitted to ER with weakness and bloody bowel movement.  He is an active daily golfer with mechanical heart valve requiring coumadin and taking aleve (ignorantly) for back pain probably against recommended practice although cannot remember doctor telling him no or ever asking.

8 units of blood and plasma given with no apparent improvement
and subsequent transfer to ICU until on day 2 endoscopic treatment locates and treats bleeding ulcer in stomach.

Bleeding continues and 8 units blood/plasma required to maintain
BP for rest of day 2 and throughout day 3 hoping for improvement
to occur.  

With no apparent improvement a 2nd endoscopic inspection reveals ulcer previously treated is NOT bleeding and no other bleeding present in stomach yet massive amounts blood still being passed.

The doctor asks my mom if we have a surgeon presumably
for exploratory reasons to find the continuing source of
bleeding.  
question 1.  can we assume both endoscopic sessions would
have inspected duodenal area for ulceration and that that
area can be ruled out along with the stomach area as source
of bleeding problems?

question 2.
My mom said they were taking him away ( out of ICU room )
day 4 (today) for more procedures and she thought they said "angiogram" to check his small and large intestines which proved
negative as to bleeding source.
I've only heard the term "Angiogram" related to inter vascular heart related obstructions etc.   Is it possible that radioactive
material can be injected into blood and views taken on
some kind of scan to see where bleeding is taking place ?

Question 3.
I feel after 4 days the situation is becomming very critical.
What type of surgeon will be needed and could we be better
off finding our own or would it be better to let the hospital
select for us ?   How and where to search ?  Are criteria
available to select surgeons with such as success rate
or fatality rate or number of times certain procedures
have been performed ?

Question 4.  Can you menition in order of probablility
the next most likely sources of continued bleeding
and possible probable recommended actions taken?
It was mentioned that bleeding could be intermittent
and may not show up on the angiograms... and that if
another bloody bowel movement takes place he will be
rushed immediately foranother scan to try to see
areas of bleeding ? ? ?

Thanks

ScottP

[Kevin Pho, MD]

To answer your questions:
1) An upper endoscopy would have appropriately evaluated the stomach and duodenal bulb.

2) An angiogram is the more comprehensive test to look for a bleeding source.  It is normally considered if the bleeding source cannot be found via endoscopy.

3) A general surgeon would be appropriate to look for the bleeding.  I cannot speak as to specific surgeons that the hospital would recommened.  It is always your choice to opt for another opinion - preferably at a major academic medical center - if the cause still cannot be found.

4) Angiography is an appropriate step.  Another consideration would be radionuclide imaging which may be more sensitive.  If the bleeding is from the small bowel, capsule endoscopy can be considered - since this can better image the small bowel than an endoscopy.

These options can be discussed with your personal physician.

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Kevin, M.D.
http://www.straightfromthedoc.com