Gastrointestinal Case 1
A 57-year-old man is brought to the emergency room (ER) for severe diffuse abdominal pain and hematemesis that began suddenly 1 hour ago. His vitals are T: 37o C, HR 107, BP: 80/54, RR: 18, O2 sat: 98%. Physical exam is only notable for diffuse abdominal tenderness. Abdominal X-ray reveals no abnormalities. Labs are notable for K: 2.8 mmol/L (N: 3.5-5.2) and a hemoglobin of 6 g/dL (N: 13.5-16.5). His past medical history is notable for hypertension, a gastric ulcer along the lesser curvature, and chronic low back pain. He reports partial compliance with his medications that include amlodipine and omeprazole. The patient also states that he has been taking ibuprofen 2-3 times per day for the past month for his back pain. Which of the following blood vessels is the most likely source of this patient’s hemorrhage?
(A) Esophageal varices
(B) Common hepatic artery
(C) Gastroduodenal artery
(D) Splenic artery
(E) Left gastric artery
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(A) Esophageal varices → dilated submucosal esophageal veins secondary to portal hypertension in patients with cirrhosis and/or liver failure
(B) Common hepatic artery → rarely eroded by a gastric ulcers along the lesser curvature due to its anatomic course toward the liver
(C) Gastroduodenal artery → most common artery eroded by duodenal ulcers
(D) Splenic artery → rarely eroded by gastric ulcers on the lesser curvature; more likely to be eroded by ulcers on the posterior wall
(E) Left gastric artery → most common artery eroded by gastric ulcers on the lesser curvature
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Middle-aged man presenting with acute severe abdominal pain and hematemesis
Tachycardic and significantly hypotensive
Diffuse abdominal pain confirmed on exam
Negative abdominal X-ray, lowering suspicion for bowel obstruction
Labs notable for hypokalemia and significant anemia (Hgb: 6 g/dL)
Partial compliance with proton pump inhibitor for gastric ulcer disease
Significant recent NSAID use for chronic low back pain
Overall, patient is at risk for complications of his gastric ulcer
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See Figures below.
Figure 1: Gastroduodenal artery comes off either proper hepatic artery or common hepatic, bifurcates into Right gastroepiploic and super pancreaticoduodenal artery. Left gastric artery is most commonly eroded by gastric ulcers
Figure 2: Duodenal ulcer at risk of eroding gastroduodenal artery. Splenic artery rarely affected by gastric ulcer. Splenic artery short gastric arteries supplies upper portion of greater curvature
