Introduction- Bleeding spots or sores on the tongue in chronic kidney disease (CKD) are frequently caused by uremic stomatitis, platelet dysfunction increasing bleeding risks, anemia, or dry mouth. The Gastroenterologist frequently treat patients with upper and lower gastro-intestinal bleed (UGIB & LGIB), the former being more common than later. The foremost important aspect is to differentiate UGIB from haemoptysis or bleeding from local source in oral cavity. It can be easily decided on basis of good history and clinical examination in majority of cases and in situation of diagnostic dilemmas, endoscopy plays a vital role.
Case Report- We are hereby reporting a fourty-six years old female, a known case of chronic kidney disease (CKD) and was on thrice weekly maintenance dialysis. She complained of minor amount of blood in vomiting for last two days. In last two days, total four episodes have occurred but amount was very less in all four episodes. There was no history of malena and in reverse, she was having constipation. On clinical examination, she was anaemic, dark coloured, moderately built but was totally conscious, co-operative, afebrile and well oriented to time, place and person. The complete hemogram revealed low haemoglobin of 8 gm/dl which was most likely due to CKD but total leucocyte counts and platelets were normal. The bleeding & clotting time and INR were in normal range. At this point of time, consultation call was sent from nephrology department to our department in night time. Hence, it was attended by junior resident on duty who after evaluation, started her on injectable proton pump inhibitors (PPI) double dose and, as she was haemodynamically stable, lined her up for endoscopy next day morning. Patient remained haemodynamically stable overnight and had one episode of small amount of blood in vomiting which according to attendants was just one or two tea spoonsful. While putting mouth guard for endoscopy, multiple red bleeding spots were noted on tongue. As, endoscopy was already planned, thus it was done and found to be normal. After completing endoscopy, again tongue was examined and tried to clear with swab, but mild ooze persisted. Hence, it cleared that bleeding was from oral cavity only and the same blood patient was spitting and the same was being interpreted as UGIB.
Conclusion- The present era is of evidence- based medicine and thus with changing time stress from good history and clinical examination has shifted to investigations-based diagnosis. In past, mentors used to teach that a good doctor can make correct diagnosis in majority of cases, on basis of detailed history and clinical examination. There was lot of stress on bed side teaching which is on downward trend these days. Our case report re-affirms the need of a detailed history and clinical examination for proper diagnosis and decreasing unwarranted investigations.
In CKD patients, there are various aetiologies for causing ulceration in mouth. It includes uremic toxins which are formed due to build up of urea in blood. Salivary enzymes break this excess urea down into ammonia, which can irritate oral tissues and cause ulcers, bleeding, or a burning sensation. Other reason can be due to platelet dysfunction because CKD impairs blood-clotting mechanisms, meaning minor tongue trauma can lead to prolonged bleeding, petechiae (tiny red dots), or ecchymosis (bruising). Oral bleeding can also be due to dry mouth (xerostomia) which can be attributed to dehydration, fluid restrictions, and medications cause dry mouth, making the tongue more prone to irritation and sores. Anemia & Immune deficiencies cause reduced red blood cell counts and a weakened immune system make it harder for mouth tissues to heal. Tongue diagnosis plays an important role in differentiation of symptoms because the tongue reflects the physiological and pathological condition of the body. Chronic kidney disease (CKD) currently is an important global public health problem and contributor to morbidity and mortality from non-communicable diseases.
CASE REPORT
We are hereby reporting a fourty-six years old female, a known case of chronic kidney disease (CKD) and was on thrice weekly maintenance dialysis. She complained of minor amount of blood in vomiting for last two days. In last two days, total four episodes have occurred but amount was very less in all four episodes. There was no history of malena and in reverse, she was having constipation. On clinical examination, she was anaemic, dark coloured, moderately built but was totally conscious, co-operative, afebrile and well oriented to time, place and person. The complete hemogram revealed low haemoglobin of 8 gm/dl which was most likely due to CKD but total leucocyte counts and platelets were normal. The bleeding & clotting time and INR were in normal range. At this point of time, consultation call was sent from nephrology department to our department in night time. Hence, it was attended by junior resident on duty who after evaluation, started her on injectable proton pump inhibitors (PPI) double dose and, as she was haemodynamically stable, lined her up for endoscopy next day morning. Patient remained haemodynamically stable overnight and had one episode of small amount of blood in vomiting which according to attendants was just one or two tea spoonsful. While putting mouth guard for endoscopy, multiple red bleeding spots were noted on tongue. As, endoscopy was already planned, thus it was done and found to be normal. After completing endoscopy, again tongue was examined and tried to clear with swab, but mild ooze persisted. Hence, it cleared that bleeding was from oral cavity only and the same blood patient was spitting and the same was being interpreted as UGIB.
DISCUSSION
Chronic kidney disease (CKD), also called chronic kidney failure, is an important global public health problem with prevalence of 11%. [2] CKD is described as a sustained reduction in glomerular filtration rate or evidence of structural or functional kidney abnormalities. [3] CKD symptoms include fatigue, persistent itching, peripheral numbness, sleep disturbances, muscle twitches and cramps, swelling of feet and ankles, nausea, and vomiting. Factors that contribute to these symptoms include anemia, uremic toxins, reduced renal capacity, chronic disease-related inflammation, and psychological stress associated with long-term illness. [4] When chronic kidney disease develops into end stage renal disease (ESRD), dialysis or a renal transplant is required to maintain life. [5] Hematemesis is the vomiting of blood, indicating acute or ongoing bleeding in the upper gastrointestinal (GI) tract. It can mimic an oral or nasal bleed if the patient experiences silent regurgitation or vomits immediately after swallowing blood. Bleeding from GI tract is never normal and can signify serious disease or a common benign disorder. At any age, swallowed blood may be misinterpreted as gastrointestinal bleeding. Swallowed blood from a nosebleed or intraoral source can be mistaken for GI bleeding. [6] In our case also, bleeding from tongue (oral cavity) mimicked upper GI bleed but it could have been easily sorted out, if good clinical examination of oral cavity had been done. Moreover, other differentiating point was complete haemodynamic stability, no malena and instead patient had constipation due to uraemia. The anemia was due to CKD because UGIB has to be very massive to make haemoglobin reach at 8 gm% and same will definitely cause haemodynamic compromise and malena.
Figure 1- Showing Multiple Bleeding Spots on Tongue
CONCLUSION
The present era is of evidence- based medicine and thus with changing time stress from good history and clinical examination has shifted to investigations-based diagnosis. In past, mentors used to teach that a good doctor can make correct diagnosis in majority of cases, on basis of detailed history and clinical examination. There was lot of stress on bed side teaching which is on downward trend these days. Our case report re-affirms the need of a detailed history and clinical examination for proper diagnosis and decreasing unwarranted investigations.
CONFLICT OF INTEREST
The authors declare that there was no conflict of interest or any kind of funding was taken for publishing this case report.
REFERENCES
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