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October 6, 2020

Image challenge: ulcers or more?

What caused a 65-year-old man to vomit four times a day with small amounts of blood and no complaints of abdominal pain or melena?
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Gastroenterology clinical image challenge: A 65-year-old man presented at the emergency department with hematemesis. The symptoms started on the day of admission and the patient had vomited four times a small amount of red blood. He did not complain of any abdominal pain or melena and was hemodynamically stable upon arrival.

The patient was a heavy smoker with a history of nonmalignant mediastinal lymphadenopathies, stroke, pacemaker implantation (sinus arrest and syncope), atrial fibrillation and intracranial hemorrhage under use of anticoagulants. Two weeks before admission, he underwent a left atrial appendage closure to stop anticoagulant use. His daily medication schedule consisted of acetylsalicylic acid, atorvastatin and bisoprolol.

Laboratory findings showed a normal hemoglobin (14.0 g/dL; reference range, 13.5–17.5 g/dL), normal liver tests and no inflammation. At the emergency department, pantoprazole was administered intravenously and patient underwent semiurgent endoscopy. This revealed pale gastric mucosa with a large gastric ulcer at the incisura angularis and some smaller ulcers in the antrum (figure A), with stigmata of bleeding but without signs of active bleeding. The esophagus and duodenum were normal.

An arterial blood sample showed an increased lactate (6.7 mmol/L; reference range, 0.5–2.2 mmol/L) and an abdominal computed tomography scan was performed. This showed the presence of a foreign body in the aorta at the level of the superior mesenteric artery (figure B, C).

What is your diagnosis?

To find out the diagnosis, read the full case in Gastroenterology.

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