Welathanthrige Savindu Pasan Botheju1, Nicola Schieferdecker2, Amit Mehta, MD3, Saurabh Mukewar, MD, MBBS4, David Wan, MD4
1Weill Cornell Medicine Qatar, Cornell University, Qatar Foundation, Doha, Ar Rayyan, Qatar; 2Ludwig Maximilians University, Munich, Bayern, Germany; 3New York-Presbyterian / Weill Cornell Medical Center, New York, NY; 4Weill Cornell Medical College, New York, NY
Introduction: Most peptic ulcer disease cases are often asymptomatic or present with dyspepsia. However, a small number present with complications such as bleeding, gastric outlet obstruction or perforation. Most of these complications can be treated with endoscopic interventions, while sometimes surgical intervention is required in cases with perforation or severe bleeding. Here we report a case of a man with a penetrating gastric body ulcer that led to massive bleeding requiring emergent surgery.
Case Description/Methods: A 65-year old male with a history of hypertrophic obstructive cardiomyopathy presented with melena, dyspnea, and lightheadedness. Prior to the melena, he had abdominal pain and consumed ten tablets of Ibuprofen daily. On presentation, he was tachycardic, anemic with a Hb of 7.4 g/dL, BUN/Cr of 51 and was given a unit of blood. Electrolytes, creatinine and coagulation profile were unremarkable. A CT A/P showed a large, deep peptic ulcer (Image 1). An EGD revealed a clean-based 5 cm non-bleeding, posterior wall gastric body ulcer with a biopsy positive for chronic active H.pylori gastritis. However, he continued to bleed and received several transfusions. A repeat EGD revealed the previous non-bleeding ulcer with a large, visible vessel (Forrest IIA) (Fig. 1) with unsuccessful hemostasis and resultant active bleeding and hemodynamic instability. An emergent laparotomy and anterior gastrotomy revealed 2L of blood in the stomach. The ulcer had penetrated the retroperitoneal tissue and vessels and was resected carefully. He was started on quadruple therapy for H.pylori.
Discussion: The prevalence of peptic ulcer disease (PUD) has been declining since the 1990s and while H.pylori prevalence has reduced, more PUD cases are being attributed to the use of NSAIDs, aspirin and anticoagulants. Some cases precipitate into severe complications such as gastric outlet obstruction, perforation, bleeding or penetration. As in this case, posterior wall ulcers are associated with penetration and hemorrhage due to the close proximity to vessels such as the gastroduodenal artery and retroperitoneal vessels and pursuing endoscopic hemostasis must be considered a high-risk procedure in these patients. Caution must be applied in such cases where a large vessel is visualized, due to the risk of exsanguination. If imaging prior to endoscopic intervention shows close proximity to a large vessel, it may be prudent to defer endoscopic treatment and consider interventional radiology or surgical intervention instead.
Citation: Welathanthrige Savindu Pasan Botheju; Nicola Schieferdecker; Amit Mehta, MD; Saurabh Mukewar, MD, MBBS; David Wan, MD. P1345 - THE PLIGHT OF THE PEPTIC ULCER: SECONDS FROM EXSANGUINATION. Program No. P1345. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.