Gastroenterology clinical image challenge: An 83-year old woman with congestive heart failure, chronic obstructive pulmonary disease and peptic ulcer disease was readmitted to our institution with recurrence of upper gastrointestinal bleeding one week after her initial episode. The patient’s initial presentation was characterized by hematemesis that occurred after she stopped her proton pump inhibitor (PPI) and in the setting of steroid use for possible polymyalgia rheumatica. An upper endoscopy at that time showed a large, 4 cm, cratered gastric ulcer with a necrotic base within the patient’s 8 cm-hiatal hernia sac. There were visible cardiac pulsations noted at the ulcer base. The appearance of the ulcer was concerning for malignancy, so the margins of the ulcer were biopsied; the results were unremarkable. An endoscopic ultrasound examination was performed to better characterize this ulcer and it revealed diffuse gastric wall thickness with no evidence of intramural or extramural mass at the site of the ulcer base. The left ventricle was seen contracting adjacent to the gastric wall at the site of the giant ulcer. The patient was restarted on twice daily PPI therapy and was discharged home in stable condition.
One week later, she represented with melena and an episode of hematemesis. On admission, her blood pressure was 120/60 mm Hg and pulse rate 81 bpm. The remainder of her physical examination was unremarkable. Her hemoglobin was 7.8 g/dL (down from 8.7 g/dL 4 days earlier). The patient was transfused one unit of packed red blood cells and underwent an upper endoscopy. Unfortunately, the patient became hypoxic after receiving propofol, so the upper endoscopy was rescheduled for the next day. The patient remained hemodynamically stable and so was her hemoglobin. She had no signs of ongoing gastrointestinal bleeding. The following day, upper endoscopy showed the large 4 cm ulcer with a protuberance in the midst of it, suspicious for a nonbleeding visible vessel (figure). The rest of the stomach was grossly unremarkable with the exception of the large hiatal hernia. There was no old or fresh blood noted throughout the examination.
How would you treat this visible vessel knowing the ulcer size and its proximity to the left ventricle? What do you think the etiology of this giant gastric ulcer is?
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