This little, old lady arrived in our ER febrile, malnourished and anemic. Her history was sort of interesting. Two weeks ago she had an open left colectomy performed at another hospital for what sounded like chronic diverticulitis. A primary anastomosis was done and she sort of lingered for a while in a nursing home afterwards. Her family resides near my part of the world and so, as she continued to not thrive, they transferred her to my hospital. She had had multiple cardiac catheterizations and was on plavix and aspirin. Her presenting hemoglobin was 7.6. WBC 9K but with significant left shift. Exam revealed right sided abdominal tenderness with some guarding. Rectal revealed frank melena. We obtained a CT scan and here's some images:
Antibiotics were started, IV resuscitation including 2 units of PRBC. She was hemodynamically stable, but just didn't "look right". I had GI do a EGD that night to rule out proximal source of blood loss. An eschar was seen over a deep duodenal ulcer in the bulb. Fortunately, it wasn't bleeding and no intervention was done other than IV Protonix. Now about those CT images. Any ideas about what's going on? What to do next?