1117 Treating an Ongoing Headache with a Gastrectomy

A 51-year-old male originally from the west coast of Africa and at the time of presentation to hospital resident in the west of Ireland, was brought in by ambulance following an unstable upper gastro-intestinal bleed. The patient was resuscitated with packed red cell transfusion and intra venous crystalloid and proceeded to definitive endoscopic management within 12 hours of presentation. During secondary survey, it transpired that the patient had been taking a supra-therapeutic dose of over the counter (OTC) non-steroidal anti-inflammatory drugs (NSAIDs) for the treatment of a headache during the preceding 8 weeks. At endoscopy, haemostasis was achieved endoscopically with a combination of subcutaneous injection of adrenaline and application of a haemostatic powder, licenced for such cases. The patient made an excellent initial recovery but on day 6 developed catastrophic secondary haemorrhage. Further endoscopic management was unsuccessful, and a decision was made to proceed to laparotomy. At laparotomy the findings included an ulcer of the distal gastric body, multiple lesions of the liver, peritoneum, and extensive lymphadenopathy. The patient proceeded to undergo an oncologic subtotal gastrectomy and D2 lymphadenectomy with biopsy of a representative liver lesion. Histology revealed the surprising finding of tuberculosis and subsequent imaging identified a large tuberculoma of the left parietal lobe as the source of original headache. This case demonstrates the importance of a wide differential list for intra-operative findings of lymphadenopathy, particularly in a globalised society and describes the unusual presentation of miliary tuberculosis, albeit indirectly, as an upper gastro-intestinal bleed.