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The bleeding grapes of wrath
  1. A D Farmer1,
  2. G J Sadler2,
  3. E T Swarbrick3
  1. 1
    Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine & Dentistry, London, UK
  2. 2
    St George’s Healthcare NHS Trust, Tooting, London, UK
  3. 3
    Royal Wolverhampton Hospital and New Cross Hospital, Wolverhampton, UK
  1. Correspondence to Dr G Sadler, St George’s Healthcare NHS Trust, Blackshaw Road, Tooting, London SW17 0QT, UK; garethsadler{at}hotmail.com

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Clinical presentation

A 73-year-old woman presented with confusion and passing blood from her ileostomy. She had undergone panproctocolectomy for ulcerative colitis 13 years previously and had subsequently been diagnosed with primary biliary cirrhosis. On physical examination she was encephalopathic with multiple signs of chronic liver disease. She was haemodynamically unstable with fresh blood and melaena being evident in the ileostomy bag. Routine haematological and biochemical parameters revealed the following: haemoglobin 10.1 g/dl, platelets 72×109/litre, prothrombin time of 16 s with normal urea and electrolytes and liver biochemistry. Abdominal ultrasound suggested appearances consistent with liver cirrhosis with moderate ascites. An ascitic tap was negative for spontaneous bacterial peritonitis. Following intravenous fluid resuscitation, an oesophago-gastro-duodenoscopy was undertaken and showed oesophageal varices in the absence of stigmata of recent haemorrhage with no blood in the stomach. The appearances of her ileostomy are shown in …

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