Chapter 491: A Mysterious Case of Persistent Bleeding

After performing an emergency gastroscopy, things looked grim for the patient.

The entire stomach lining appeared pale, which meant the patient had gastritis—and it was severe.

Erosion, ulcers or swollen inflamed patches on the surface usually cause this kind of change.

No wonder the patient looked so thin. His father complained the boy spent his days gaming or running wild, barely eating at home. With gastritis that bad, symptoms like nausea, vomiting, indigestion, acid reflux and burning would be a given.

Really, how can you expect someone to have an appetite with a stomach like that?

Most of the time, gastritis develops because of irregular eating habits—skipping meals, overeating, drinking on an empty stomach, or always going for spicy barbecue.

In short, people usually bring gastritis on themselves.

When you’re healthy, you don’t think twice about wearing your body down.

Eventually, the organs that take the most abuse can’t keep up and start failing. That’s when you get sick.

The gastroscopy showed an old, narrow strip of bleeding on the posterior wall of the gastric fundus. Along the greater curvature of the stomach there were areas of superficial erosion, with whitish secretions and spots of recent bleeding.

The gastric antrum and duodenal bulb looked normal.

A rapid urease test came back negative.

At this point, the cause behind the illness was mostly clear.

It was, plain and simple, a case of gastrointestinal bleeding.

After some discussion, Dr. Ai Li and Zhou Can decided to start with a blood transfusion and intravenous hemostatic drugs.

Almost every responsible doctor will try meds first to treat a disease. Surgery is only an option if medication fails.

After all, any surgery causes trauma to the patient’s body.

“Dr. Zhou, do you think batroxobin would work as a hemostatic for this case?”

“Just one drug isn’t enough. How about adding tranexamic acid to the mix?”

Zhou Can replied.

Batroxobin works fast to stop bleeding, so it’s widely used in emergencies like this. Tranexamic acid has a strong and lasting effect, suppressing the fibrinolytic system—so it’s great for fighting bleeding after major surgeries, including those in surgery and obstetrics.

Plus, it has a powerful edge: it can cross the blood-brain barrier. That’s why it’s commonly used to manage bleeding in the central nervous system.

After handling this case, Zhou Can hurried to the operating room.

He told Dr. Ai Li that if these treatments didn’t work, they’d have to come up with a new plan.

……

Past noon, Zhou Can wrapped up surgery and headed to the cafeteria with his team.

Just as he passed the triage desk, Dr. Ai Li called him over.

“Dr. Zhou, back from surgery?”

“Yeah, today’s emergency cases piled up, so we ran late in the OR.”

Some surgeries really can’t wait and need urgent attention.

Like stopping bleeding and suturing wounds for injuries.

Or reattaching severed fingers.

In the past, the Emergency Department rarely did finger reattachments—it’s a highly technical operation, and only Dr. Xu could pull it off. Plus, it takes forever.

So if Dr. Xu was busy with a finger reattachment when another emergency needed surgery, they’d be seriously short-staffed.

Urgent procedures, especially wound sutures, dog bites, or trauma from falls—these all need the Emergency Department on top of it. If they pushed every case to a specialty department, they’d be flooded with complaints.

A few years back, Director Xie almost sparked a huge conflict with Deputy Director Ye because the ER did a few too many surgeries.

Truth is, Tuyu always has plenty of minor surgical cases coming in.

For a famous national Grade A hospital like this, with a solid reputation in the province, patient numbers have been skyrocketing every year.

Every department gets its fair share, sometimes too much—some specialty units get so many patients with minor issues, they have to turn them away.

So now, specialty departments have this paradox: the fewer simple cases, the better. What they really want are moderate to severe, complicated cases.

Departments mainly rely on serious and difficult cases to boost earnings.

Severe cases also fill beds to capacity, which is good for the department’s performance.

If the Emergency Department just dumped the treatable, straightforward cases onto specialty departments, they’d be in big trouble. Ultimately, it’s all about interests.

These days, the Emergency Department’s OR is thriving. There’s a standard operating room, a top-tier sterile suite, and an endoscopy OR under construction.

The surgical team has grown from a handful to about twenty-five or twenty-six people.

That includes over a dozen surgeons and more than ten surgical nurses.

Now, even if Zhou Can or Dr. Xu takes time off, the Emergency Department runs just fine.

“Dr. Zhou, could you take another look at that upper GI bleeding patient? After transfusing a thousand milliliters, the condition’s improved, but the bleeding hasn’t stopped and the patient has a high fever—temp’s up to 39.4 degrees.”

Dr. Ai Li felt a bit embarrassed asking Zhou Can yet again for help.

She was nearly fifty and an attending doctor, but she’d lost count of how many times she’d asked this resident in his twenties for advice.

In fact, she’d just gotten used to it by now.

“Let’s go check on that patient together,” Zhou Can said.

The patient had to come first.

“Dr. Zhou, I’ll save you some lunch, okay?” Qiao Yu quietly looked after Zhou Can in daily life.

It was already late, and she worried the cafeteria might run out of food.

“You all eat first, I’ll grab something after I finish here,” Zhou Can replied.

He’d realized this upper GI bleed was going to be a tough one.

There was no telling how long it might take.

Why did the patient spike a high fever within just three or four hours after taking medication?

Following Dr. Ai Li into the resuscitation room, Zhou Can saw the patient lying with eyes shut, face still pale. But compared to that morning, there’d been marked improvement.

Getting a thousand milliliters of blood transfusion was already quite something.

“Did you use ranitidine?”

After reviewing the case, Zhou Can asked Dr. Ai Li.

In the Emergency Department, whoever admitted the patient is responsible for them from start to finish.

New doctors panic at the thought of getting a critically ill patient.

But as long as an attending or above is on duty, they’ll rush to help with emergencies—never dumping critical care on rookies.

“Yes, we did,” Dr. Ai Li nodded.

She confirmed it.

Ranitidine is commonly used for duodenal and gastric ulcers, reflux esophagitis, Zollinger-Ellison syndrome and other disorders with high gastric acid. Sometimes it’s used for infections with Helicobacter pylori.

Right now, figuring out the cause of the fever had Dr. Ai Li stumped.

That was her main reason for asking Zhou Can for help.

“All other vital signs look stable—no chills, just this high fever. It’s honestly odd. We can’t rule out an intestinal infection.”

Zhou Can frowned, focusing all his attention to diagnose the problem.

Transfusions almost never cause high fevers. He could rule that out.

Dr. Ai Li had been extra careful with meds, sticking only to the two hemostatic drugs they’d agreed on. Ranitidine was routine for gastric ulcers.

The risk of fever from medication should have been very low.

And yet, after just three or four hours of treatment in the hospital, the patient had developed a high fever.

Nurses’ charts showed that the patient’s temperature climbed steadily over four hours—there was no sudden spike.

So this wasn’t a typical acute fever.

The first thing to check was still the meds.

Zhou Can’s pathology skills were level five—almost up to an associate chief physician. He’d only just reached intermediate associate chief in pharmacology.

But there was still a gap between the two.

With a thousand milliliters of blood, the patient’s hemoglobin had barely returned to an acceptable level. Even so, the anemia hadn’t really improved much.

Zhou Can reread the emergency gastroscopy report.

Normally, mucosal erosions in the stomach wouldn’t cause so much bleeding that the patient developed severe anemia, or even went into shock—not even after a month of constant bleeding.

So where was the real problem?

At this point, Zhou Can was starting to doubt whether simple gastritis was the actual cause of this bleeding.

Plus, erosive hemorrhagic gastritis usually stops bleeding on its own pretty quickly. But this patient had passed black stool for over a month—that didn’t add up.

Another sign it wasn’t just gastritis causing the bleeding.

His mind raced, running through the possibility that the bleeding source was somewhere else.

For anemia this severe, or even shock, the bleeding had to be massive.

If there was heavy bleeding in the stomach or duodenum, the blood would back up into the stomach—and the patient would vomit ‘coffee ground’ stomach contents, or even just pure blood.

Like in the Three Kingdoms, where Zhuge Liang supposedly cursed Wang Lang until he spat blood on the spot.

Of course, novels say Wang Lang died when his heart meridian snapped, but that’s stretching things.

The heart sits in the chest cavity—ruptured blood vessels there almost never cause vomiting blood. It’s almost always massive bleeding from the upper GI tract or upper airways that does that.

Airway bleeding more often brings up frothy blood.

For sudden bloody vomiting collapses, doctors look at the color of blood from the mouth and nose and whether it’s bubbly—that tells you where it’s coming from.

Blood from the lungs usually means a cough, with frothy blood—that’s hemoptysis.

Bleeding from the stomach or duodenum means vomiting bright blood.

But this patient didn’t report any vomiting.

That made massive upper GI bleeding very unlikely in the short term.

Still, right before this last episode, the patient had a sudden nosebleed—a detail that shouldn’t be ignored.

The anatomy of the throat and nose is intricate.

The nasal mucosa is loaded with blood vessels—get overheated or take a blow to the nose, and nosebleeds are common.

Sometimes, those nosebleeds can get pretty scary.

But neither the patient nor family reported frequent nose bleeding. So that clue could wait.

The top priority now was to pin down the real source of the bleeding, fast.

Even after resuscitation, the patient’s vital signs had stabilized for now—but without a true diagnosis, things could go bad in a heartbeat.

After admission, the patient only developed a fever after getting fluids and blood.

Coincidence, or something deeper?

Only three drugs went into the fluids: ranitidine for the ulcer, batroxobin and tranexamic acid for bleeding. None of these should spike a fever so quickly.

At least going by Zhou Can’s clinical experience and pharmacology knowledge, a drug fever seemed impossible.

Could a transfusion bring on a fever?

He had to admit, he’d never heard of that happening so fast.

“Dr. Ai, call in the nurse who administered this patient’s fluids. Let’s meet in the office to discuss.”

Zhou Can needed to rule out transfusion and infusion reactions first.

Maybe there was an issue with the saline.

That was the immediate thing to check.

Sometimes, a batch of saline might get contaminated during production or storage.

Like if clumps or strands form inside the bottle.

A good, attentive nurse always triple checks, even shaking the bottle to see if anything’s off before starting an infusion.

Saline is one of the most used hospital drugs.

When hospitals buy, every supplier tries to outdo the rest.

Of course, some shady suppliers might cut corners and deliver bad product.

But in general, manufacturers are scared of problems and want long-term business, so most keep a strict check on safety.

Still, maybe a worker slipped up, or the factory equipment was old and faulty—the occasional bad batch is possible.

It’s not every bottle, only a rare one in thousands.

But if that unlucky bottle goes to a patient, it could be disastrous.

And the odds are always there.

In the office, the nurse, Dr. Ai Li and Zhou Can sat down to discuss the case.

Zhou Can led the discussion.

“Zhao, when you set up the IV, did you check the bottles?”

Zhou Can would never ask this in front of the patient or their family.

That’s exactly why he’d gathered the nurse and Dr. Ai Li privately.

“I made a point to check—it all looked fine. Chief Niu always reminds us to be super careful every time, safety first. We’re always extra vigilant before each patient’s infusion.”

Zhao Qian and Zhou Can were old colleagues by now.

She really worked hard on the job.

She’d just been promoted to nurse, but she still had a long way to go to make head nurse.

For nurses, advancing up the ranks is as tough as it is for doctors.

It’s still comparatively easier for doctors to make attending.

For nurses hoping to become head nurses, it’s all about experience or a graduate degree. Of course, having connections changes the game.

Society runs on relationships, especially here. In some workplaces—like the national railroad company or hospitals—the cushy desk jobs go to the ‘second-generation’ crowd.

Zhou Can knew Zhao Qian’s work ethic well.

She was always diligent and hardworking.

Since she’d checked the IV bottles so carefully, Zhou Could basically rule out a problem with the infusions.

After serious thought, Zhou Can figured the patient probably had multiple bleeding sources.

What does multiple sources mean?

It means more than one site is bleeding.

This patient likely had more than just upper GI bleeding.

The small intestine and upper colon deserved special investigation. Checking gastric secretions was also important.

Given he’d passed black stool for over a month, a major stomach bleed was still in play.

In medicine, unless you have rock-solid proof, you never rule out any possibility—just weigh each one based on likelihood.

Especially with tough, rare cases like this, it’s often an overlooked detail behind the illness.

Rare cases mean rare causes or rare symptoms—ones you won’t find in the textbooks.

Doctors have to depend on their real-world experience to solve the puzzle.

“Dr. Ai, I’d suggest regular sampling of gastric secretions to monitor for bleeding. Let’s also use auxiliary tests to check for possible sources in the small intestine and colon.”

Zhou Can gave concrete next steps for further diagnosis.