Krutika Lakhoo, MD
Hospitalist
Cedars Sinai Medical Center
Los Angeles, California
Krutika Lakhoo, MD, Pedram Enayati, MD
Cedars-Sinai Medical Center, Los Angeles, CA
Introduction: Gastrointestinal bleeding is a common inpatient diagnosis with a cost >$5 billion in the US. Typically patients undergo endoscopic evaluation, capsule studies, CT imaging with/without embolization and in severe bleeding, surgical management may be pursued. We present a case of recurrent GI bleeding due to factitious disorder
Case Description/Methods: 52-year-old female veterinary tech with a complex surgical history presented to the ER for acute recurrent hematemesis with bright blood seen in ER. In 2017, she developed recurrent upper GI bleeding. Previous EGD showed Dieulafoy lesions that were clipped and she underwent partial gastrectomy. Physical examination showed normal vitals and diffuse mild abdominal tenderness. Labs showed stable normocytic anemia (Hgb 9-10), normal iron stores, LFTs, INR, and platelets. She underwent extensive workup including angiogram, multiple endoscopies, and multiple CTA A/P with no identifiable source of bleeding. Given ongoing visualized bleeding and almost weekly hospitalizations she underwent remnant gastrectomy for definitive management and pathology confirmed Dieulafoy lesions. During the hospitalization, she was found to have 2 blood-filled syringes in her pillowcase. She had multiple concerning signs for a psychiatric disorder: "la belle indifference", no active bleeding on endoscopy, no melena, persistent bleeding despite gastrectomy, stable Hgb, female with medical training, and no further bleeding after sitter placed. Psychiatry team was consulted and discovered she had been ingesting blood drawn from a PICC line to stimulate bleeding. A diagnosis of Munchausen’s disorder was made
Discussion: Munchausen’s disorder occurs when patients intentionally produce physical or psychiatric symptoms (usually of dramatic nature), allowing them to assume a sick role and gain medical attention. This is a difficult diagnosis and often results in the excessive use of medical resources. Risk factors include a serious illness/trauma during childhood, loss of a loved one, personality disorder, and being a healthcare worker. The motive is mainly to gain sympathy and attention. Physicians should confront patients with the diagnosis if a good therapeutic relationship has been established and patients benefit from psychotherapy and close medical and psychiatric follow up. Prognosis tends to be poor however, with most patients refusing psychiatric evaluation and leaving AMA. This case adds to literature suggesting factitious disorder with hematemesis is not as rare as expected
Citation: Krutika Lakhoo, MD, Pedram Enayati, MD. P1337 - SEEING ISN’T ALWAYS BELIEVING! RECURRENT HEMATEMESIS DUE TO FACTITIOUS DISORDER. Program No. P1337. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.