Upper GI bleeding, Gastric tumors, Melena
An informed consent was obtained from our patient.
An 80-year-old man suffering from dementia and Parkinson disease was admitted to our hospital for investigation of 2 to 3 daily episodes of melena stools 20 days now. At his first presentation, he was hemodynamically stable and his initial hemoglobin was 10 g/dL (normal limits: 13-18). His past medical history was significant for weight loss (10 kg) and fatigue for the previous 3 months. There was no remarkable family history. The patient denied smoking, drinking alcohol, taking analgesics, or any other drug abuse (except for the dementia and the Parkinson disease), and his complete blood count revealed an iron-deficiency anemia.
During the upper GI endoscopy, we noticed to our surprise the presence of a sizable ulcerative lesion occupying the second half of body of the stomach on the lesser curve, exactly above the gastric angle (Figure 1), which was covered by a black-yellowish coating with irregular margins and with no active bleeding. Apart from this finding, nothing else was revealed. Biopsies were taken with great difficulty due to the hard consistency of the ulcerative margins of the lesion. The tissues were sent for histopathological evaluation which revealed a high-grade gastric adenocarcinoma.
Gastric cancer accounts for 2-3% of all cases of severe upper gastrointestinal bleeding (UGIB) [1]. Patients with bleeding secondary to malignant upper gastrointestinal tumours have a poor prognosis [2]. Acute bleeding represents a late stage of disease when the tumour causes mucosal ulceration or erosion into an underlying vessel. Initial assessment and resuscitation should be performed according to the general guidelines for the management of UGIB. Endoscopy is critical for the diagnosis and primary treatment within 24 hours of presentation. Bleeding scoring systems, such as the Glasgow-Blatchford bleeding score (GBS) and the Rockall score, which evaluate clinical findings, and the Forrest classification of endoscopic images are helpful in managing tumor bleeding [3,4]. Endoscopic treatments for bleeding upper gastrointestinal tumours include injection therapy, thermal contact probes, Hemospay and laser therapy. Control of active bleeding can be successful, but rebleeding is common [5]. Surgical resection for cure or palliation is the final treatment of choice. Medical therapy is usually palliative and consists of chemotherapy and/or radiation therapy. In conclusion, although rare, a malignancy of stomach should be always considered in older patients presented with UGIB.
Figure 1: Endoscopic image, in retroflexion view, showing a large tumor on the lesser curve and posterior face, immediately above the gastric angle, confirmed on biopsies as a high- differentiated adenocarcinoma.