48uep6bbphidcol2|ID
48uep6bbphidvals|1932
48uep6bbph|2000F98CTab_Articles|Fulltext
A 33-year old male, a chronic smoker, presented to us with sudden onset of haematemesis. He had recently undergone a urological procedure and been on continuous bladder drainage. Examination revealed pulse rate of 110/minute, blood pressure 90/60 mmHg and pallor. Laboratory tests showed anaemia, thrombocytopenia and mild elevation of transaminases. Upper endoscopy was unremarkable following which he developed another bout of haematemesis. Repeat endoscopy showed only fresh blood in the oesophagus and stomach. His hypotension worsened requiring resuscitation with intravenous fluids. As he was being stabilized, interrogation of a relative who accompanied him provided evidence that the patient had recently undergone substitution urethroplasty using buccal mucosal graft. Oral examination revealed bleeding from the upper lip. Local tamponade was immediately applied using a pressure pack. The on call dental surgeon identified the superior labial artery (Figure 1) as the source of bleeding which was immediately ligated and haemostasis achieved.
Discussion
This patient presented to us with history suggestive of haematemesis. Common causes of haematemesis include peptic ulcer, esophagitis, variceal bleed, tumours etc1. Rare causes include disorders of haemostasis, aortic aneurysm, infectious causes like malaria, dengue, scarlet fever, infective endocarditis and swallowed blood (epistaxis, haemoptysis, bleeding from the mouth or throat). Initial gastroscopy was unyielding but subsequent procedure showed fresh blood raising suspicion of swallowed blood. Although the details of the surgical procedure were not available, the history provided by the relative that a procedure was performed involving mouth as well as urethra gave us the clue that the bleed was probably from oral cavity. The exposed superior labial artery in the raw graft-bed site bled was the cause of bleed.
Buccal mucosal graft harvesting for urethroplasty is usually done from the cheek. It is associated with complications including bleeding, post-operative infection, pain, swelling, salivary duct disorders, restricted mouth opening, scar formation, contracture and loss of sensation due to nerve injury2. Bleeding is reported in 1 to 5% of patients. In a retrospective review of 128 patients from 2001 to 2015 who underwent buccal mucosal graft harvesting, bleeding from oral cavity was reported in only 1 patient (0.7%)3. The predictors of graft site complications were graft size, site of harvesting, open dressing at site of harvesting especially from the lower lip and avoidance of using cautery to prevent nerve injury2.
In hindsight, we learnt that endoscopy could have been avoided had a more detailed history taking and oral examination been performed in the first place. Ultimately it was the interrogation of the patient’s relative that led us to the source of bleed which was much nearer than we suspected.
References
- Simon Anderson. Haematemesis. In: Kinirons MT, Ellis H editors. French’s Index ofDifferential Diagnosis An A-Z 16th ed. New York: CRC Press; 2016. p. 238.
- Evaluation of intraoral complications of buccal mucosa graft in augmentation urethroplasty. Akyüz M, Günes M, Koca O etal. Turkish Journal of Urology 2014; 40(3): 156-60.
- Buccal mucosal graft urethroplasty in men—risk factors for recurrence and complications: a third referral centre experience in anterior urethroplasty using buccal mucosal graft. Spilotros M, Sihra N, Malde S et al. TranslAndrolUrol2017;6(3):510-516.