A 73-year-old man was displaying symptoms of massive gastrointestinal (GI) bleed. Surgical actions were performed to control the bleed caused by an erosive duodenal ulcer with duodenal perforation. When investigating the culprit of this case, the pain medications prescribed two weeks prior by a traditional Chinese medicine doctor raised attention. The patient's admission serum sample and the pain medications from unknown sources were analyzed using a clinically validated liquid chromatography-high-resolution mass spectrometry (LC-HRMS) method. The NSAIDs diclofenac, piroxicam, and indomethacin were identified, as well as some other synthetic drugs and natural products. The patient's concurrent exposure to multiple NSAIDs significantly increased the risk of upper GI complications. It is reasonable to argue that the high-dose use of the NSAIDs was a major cause of the duodenal ulcer and GI bleed. In addition, the identified natural products such as atropine and ephedrine have well-documented toxicities. It is important to increase the visibility of unregulated medications, and the capability to perform untargeted mass spectrometry analysis provides a unique diagnostic advantage in cases where exposure to toxic substances is possible.

中文翻译：

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一例不明原因的十二指肠溃疡和大量消化道出血。

一名 73 岁男子出现大量胃肠道 (GI) 出血症状。进行外科手术以控制由十二指肠穿孔的糜烂性十二指肠溃疡引起的出血。在调查这起案件的罪魁祸首时，一位中医师两周前开出的止痛药引起了人们的关注。使用临床验证的液相色谱-高分辨率质谱 (LC-HRMS) 方法分析患者入院时的血清样本和来源不明的止痛药。非甾体抗炎药双氯芬酸、吡罗昔康和吲哚美辛以及其他一些合成药物和天然产物已被鉴定。患者同时暴露于多种非甾体抗炎药显着增加了上消化道并发症的风险。有理由认为大剂量使用非甾体抗炎药是十二指肠溃疡和胃肠道出血的主要原因。此外，已确定的天然产物如阿托品和麻黄碱具有充分记录的毒性。增加不受管制药物的可见性很重要，并且在可能接触有毒物质的情况下，执行非靶向质谱分析的能力提供了独特的诊断优势。