タイトルは、「もうそんな時代じゃないよ」という意味を込めて、"Obscure Gastrointestinal Bleeding (OGIB)" に対する皮肉なのでしょう。

Word Count：2553語 (Time: 13'20'', 191 wpm)

参加人数：４名

クリニカル・パール：

Angioectasias occur most commonly in elderly patients, especially in those with renal failure or aortic stenosis.
Angioectasias are also increasingly recognized in patients with either pulsatile or nonpulsatile LVADs.
In patients with either aortic stenosis or an LVAD, a narrow pulse pressure may result in hypoxia of intestinal tissue with subsequent vascular dilatation and angioectasia formation.
Both pulsatile and nonpulsatile LVADs induce platelet dysfunction through inhibition of von Willebrand factor
Their pathogenesis is uncertain but may be associated with aging-related chronic obstruction of submucosal veins that extends to venules, capillaries, and arteries and ultimately results in loss of precapillary-sphincter competency and development of arteriovenous communications.
According to one report, gastrointestinal bleeding is more common among patients with nonpulsatile LVADs than among patients with pulsatile LVADs (20% vs. 10%).
The elevated blood urea nitrogen level raises the possibility of an upper gastrointestinal source, although it may simply reflect volume depletion.
On presentation, the history of hematochezia followed by melena suggested a lesion of the upper gastrointestinal tract, small bowel, or cecum.
In patients with aortic stenosis, large von Willebrand factor multimers, which promote platelet aggregation and clotting, are cleaved to small fragments (which do not promote platelet aggregation) as they pass through an environment with high shear force.

感想：

本症例は、LVADが原因でしたが、ASであれば、"Heyde's syndrome"と称されるもの。そして、その名前の由来は、1958年NEJMに掲載されたレターでした。一臨床医でも名前を残せるという勇気を与えてくれると同時に、巨人の肩を借りつつ積み上げていく医学の歴史を実感できる機会となりました。
蛋白が、化学的に変性するのではなく、血流のshear stressで分解して病気を起こすというのが意外でした。
ブルガダ３兄弟の本 "Our Most Beloved Electrocardiograms"（邦題：「ブルガダ三兄弟の心電図リーディング・メソッド82 」）に準えて、"Our Most Beloved Cases" を企画すれば、個人的には筆頭の症例です。

函館稜北病院総合診療科抄読会Ｂ面