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Endoscopic Finding of Large Gastric Diverticulum with Ulceration: A Rare Cause of Upper Gastrointestinal Bleeding
OJ01-OJ02
Correspondence
Nikhil Pantbalekundri,
Resident, Department of General Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Sawangi (Meghe), Wardha-442004, Maharashtra, India.
E-mail: nikhil2623pant@gmail.com
A 60-year-old male patient presented to the casualty with complaints of multiple episodes of bloody vomiting, burning epigastric pain, generalised weakness, giddiness, and passing black tarry stools for five days. The epigastric pain had an insidious onset, a burning character, was intermittent, non-radiating, aggravated after consuming spicy food, and relieved by taking some antacid medication. He also had nausea followed by multiple episodes of vomiting, containing fresh red blood, around 1-2 teaspoons in each vomit, with some reddish-black clots. He also had a past history of a burning sensation in the epigastrium for one year. He had no significant family history.
Upon examination, he was found to be hypotensive (blood pressure: 90/60 mmHg), tachycardiac (heart rate: 102/min), and tachypnoeic (respiration rate: 24/min); he also had pallor. Laboratory tests revealed normocytic normochromic anaemia (haemoglobin: 8.2 gm%). Stool for occult blood was positive. During endoscopy, a large opening was observed arising from the posterior wall of the stomach body, showing an ulcerated surface with visible blood vessels, suggestive of Gastric Diverticulum (GD) with ulceration (Table/Fig 1).
Contrast Enhanced Computed Tomography (CECT) of the abdomen revealed a well-demarcated saccular outpouching at the lesser curvature of the stomach body, suggestive of GD (approximately 6.6×4.8 cm) (Table/Fig 2).
An endoscopy-guided biopsy was taken from the diseased area. The biopsy specimens were stained with Haematoxylin and Eosin stain (A-low power view: 10x [Table/fig: 3(a)] and B-high-power view: 40x [Table/fig: 3(b)]) and showed mucosal atrophy with mild dysplastic changes. The underlying submucosal tissue showed an abundant chronic inflammatory infiltrate composed predominantly of lymphocytes and plasma cells. Occasional neutrophils and eosinophils were also seen, along with congested blood vessels. The histopathological features were suggestive of “Chronic Gastritis.” The diagnosis of normocytic normochromic anaemia with a large GD and chronic gastritis was made.
He was advised to undergo diverticulectomy and, if required, subtotal gastrectomy. However, he was unwilling to undergo surgery. As a result, he was managed conservatively with proton-pump inhibitor infusion (Pantoprazole-80 mg i.v. bolus followed by 8 mg/hour for another 72 hours), sucralfate (2 teaspoons thrice daily for eight days), and blood transfusion (2 units of packed red cells) during his two-week stay in the hospital. He was discharged after stabilisation on proton pump inhibitors (Esomeprazole 40 mg daily for 3 months) and a haematinic (Ferrous Sulfate 325 mg tablet for 3 months), with a haemoglobin level of 10.9 gm% at the time of discharge. After three months, the patient was followed clinically and was found to be symptomatically better, i.e., he had no epigastric burning pain, bloody vomiting, giddiness, or black stools thereafter.