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Image challenge: Gastric ulcer in a patient with metastatic lung cancer

What caused a gastric ulcer in a patient presenting with abdominal pain, nausea and vomiting occuring after a chemotherapy cycle?

Gastroenterology clinical image challenge: A 74-year-old man presented with recurrent abdominal pain, nausea and vomiting. His medical history includes recently diagnosed stage IV non-small cell lung cancer that was treated with two cycles of carboplatin, pemetrexed and pembrolizumab. He also underwent palliative radiation for treatment of bone pain related to metastatic lesions. The patient presented to the emergency department twice with abdominal pain, nausea and vomiting that occurred after each chemotherapy cycle. Each time he was managed conservatively with intravenous fluids, antiemetics and opioid analgesics. On his third presentation to the emergency department, he was admitted for further workup of his recurrent symptoms. He reported a recent history of daily nonsteroidal anti-inflammatory use.

On examination, he was noted to be hemodynamically stable. The physical examination was unremarkable and there was no abdominal tenderness. Laboratory studies were remarkable for a normocytic anemia of 11.0 g/dL (baseline of 13 g/dL). A computed tomography scan of the abdomen and pelvis with intravenous contrast was concerning for possible edema of the gastric wall. An upper endoscopy was subsequently performed and was remarkable for a large antral ulcer with a nonbleeding visible vessel. A total of four hemoclips were deployed and biopsies of the ulcer edge were obtained. Histology of the gastric ulcer revealed ulcerated gastric mucosa with a rare focus of cryptitis and a rare crypt with apoptotic epithelial cells (Figure).

What is the most likely cause of this patient’s gastric ulcer?

To find out the diagnosis, read the full case in Gastroenterology or download our Clinical Image Challenge app through AGA App Central, which features new cases each week. Sort and filter by organ, most popular or favorites. AGA App Central is available in both the Apple App Store and Google Play

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