title: Upper gastrointestinal hemorrhage after nonresponsive thoracic spine pain: a case report.
abstract: OBJECTIVE
  This case study reports the findings of an upper gastrointestinal hemorrhage in a patient with thoracic spine pain reporting to a chiropractic clinic. The purpose of this article is to highlight the importance of identifying a patient's medication history as well as reviewing the signs and symptoms of gastrointestinal bleeding from a nonvariceal lesion.
  
  
  METHODS
  A 61-year-old woman presented with worsening middle thoracic spine pain of 3 months' duration along with recent abdominal pain. Medications, physical therapy, and spinal manipulation did not provide considerable improvement. The patient was taking ibuprofen daily to cope with her back pain.
  
  
  RESULTS
  The initial physical examination demonstrated mild increased tissue tension in the thoracic paraspinal muscles with mild restriction of thoracic spine range of motion secondary to the patient's pain. There was pain on palpation of the T4-5 and T7-8 spinal segments. The physical examination findings did not correlate to the patient's pain presentation, and she was referred back to her primary care physician. Two days after the initial examination, the patient experienced an upper gastrointestinal hemorrhage and underwent emergency surgery. It was determined postoperatively that she had a medication-induced duodenal ulcer that subsequently ruptured.
  
  
  CONCLUSIONS
  An upper gastrointestinal bleed should be considered in the differential diagnosis of a patient with a history of prolonged aspirin or nonsteroidal anti-inflammatory drug use with nonspecific abdominal symptoms.
authors: Instructor of Chiropractic Science and Research, Division of Research, Logan College of Chiropractic, St. Louis, MO 63006.
authors: James W
authors: JW
authors: George
authors: Clayton D
authors: CD
authors: Skaggs