Stress-related massive gastrointestinal bleeding in a diabetic and obese woman following double leg amputation.

Foot ulceration is a leading cause of hospital admission for patients with diabetes mellitus and the main reason for major amputation. This study presents the rare association of double amputation of both legs within 16 months of each other, a rarer outcome of diabetic foot ulcer disease, and the fatal complication of massive stress-related gastrointestinal bleeding that occurred thereafter leading to haemorrhagic shock and sudden death. On an index patient the clinical management was reviewed, a detailed autopsy performed after demise, and an extensive literature review including MEDLINE searches were carried out. Autopsy study revealed 3 ulcers in the gastric body and 1 in the gastric antrum measuring between 0.5 and 1cm and associated with about 2.5 litres of clotted blood in the gastrointestinal lumen extending from the stomach to the sigmoid colon. The patient combined physical stress factors for gastric ulceration which include uncontrolled diabetes mellitus prior to amputation, massive trauma from lower limb amputation with delayed wound healing, intake of non-steroidal anti-inflammatory drugs in the setting of past medical history of successfully treated peptic ulcer disease and the emotional stress factor of depressive illness related to the loss of her second lower limb. This association has not been reported in literature and with this we wish to warn clinicians to look out for this fatal complication in managing patients with advanced diabetic foot ulcer disease especially those going for a second limb amputation.