[Acute upper gastrointestinal bleeding after coronary intervention in acute myocardial infarction].
METHODS
A 73-year-old man with NSTEMI (non-ST segment elevation myocardial infarction) underwent coronary angiography and an in-stent restenosis and thrombosis in ramus circumflexus was found. A drug-eluting stent (DES) was implanted. 12 h after intervention during threefold platelet inhibition the patient presented a gastrointestinal bleeding with melena and the hemoglobin level dropped from 15.3 g/dl to 9.7 g/dl.


METHODS
Blood tests revealed a considerable elevation of cardiac enzymes, troponin I, leukocytes and C-reactive protein but normal hemoglobin. In coronary angiography, the stent in ramus circumflexus was found to be occluded. Therefore, a percutaneous coronary intervention with implantation of a DES (Taxus) was performed. In gastroscopy, a 2.5-cm necrotic formation resembling a tumor with an oozing bleeding was identified. The bleeding was stopped after injection of adrenaline. Histological evaluation showed no criteria of malignancy.


METHODS
With high-dose proton pump blocker therapy, calculated Helicobacter pylori eradication with amoxicillin and clarithromycin, and cessation of NSAID (nonsteroidal anti-inflammatory drugs), the hemoglobin level was stable with 9.7 g/dl. No blood transfusion and no interruption of the dual platelet inhibition were necessary. In control gastroscopy, the initial endoscopically malignancy-suspicious formation presented as a small, superficial, healing ulcer.


CONCLUSIONS
Bleeding complications after stent implantation create a dilemma situation. The risk of a hemorrhagic shock by continuing platelet inhibition therapy and the risk of an acute stent thrombosis with interruption of the platelet inhibition should be carefully calculated considering individual facts and the guidelines.
Strobl
Stefanie
S
Klinik und Poliklinik für Innere Medizin 1, Universitätsklinikum Regensburg, Regensburg, Germany. Stefanie.strobl@klinik.uni-regensburg.de
Zuber-Jerger
Ina
I
D000368:Aged; D000658:Amoxicillin / Q000627:therapeutic use; D015906:Angioplasty, Balloon, Coronary; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D017291:Clarithromycin / Q000627:therapeutic use; D003131:Combined Modality Therapy; D023903:Coronary Restenosis / Q000628:therapy*; D004359:Drug Therapy, Combination; D054855:Drug-Eluting Stents; D005753:Gastric Mucosa / Q000473:pathology; D006471:Gastrointestinal Hemorrhage / Q000139:chemically induced* / Q000628:therapy; D005773:Gastroscopy; D016481:Helicobacter Infections / Q000175:diagnosis* / Q000628:therapy; D016480:Helicobacter pylori; D006801:Humans; D008297:Male; D009203:Myocardial Infarction / Q000628:therapy*; D009336:Necrosis; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage / Q000009:adverse effects*; D054328:Proton Pump Inhibitors / Q000627:therapeutic use; D013272:Stomach Diseases / Q000139:chemically induced* / Q000628:therapy; D013276:Stomach Ulcer / Q000175:diagnosis* / Q000628:therapy
D000900:Anti-Bacterial Agents; D010975:Platelet Aggregation Inhibitors; D054328:Proton Pump Inhibitors; D000658:Amoxicillin; D017291:Clarithromycin
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