Not so visible vessel upper gastrointestinal bleeding from large protruding vessel from pre-pyloric ulcer mimicking a fibrin clot. These are author's disclosures. Background upper GI bleeding is caused by peptic ulcer disease in 50 to 60 percent of cases. Rarely peptic ulcer disease exposes the submucosal vessel that may result in life-threatening hemorrhage. Risks of re-bleeding from non-bleeding vessel forest 2a ulcer is 43 percent versus 22 percent from ulcer with adherent clot which is forest 2b ulcer. Forest 2a ulcers occasionally mimic the appearance of a fibrin clot on EGD as described in our case. Case presentation a 53 year old man with history of atrial fibrillation on Apexaban presented with multiple episodes of bright red bleeding per rectum and an episode of hematomasis. His initial vitals are heart rate 110 per minute blood pressure 75 over 51. On initial examination he was lethargic and had epigastric discomfort. His hemoglobin was 6.1 baseline hemoglobin 11. CT and geo-abdomen showed blood clots in stomach without active bleeding. After initial resuscitation with IV fluids and multiple blood transfusions a bedside upper endoscopy was performed that showed blood and clots in the gastric body and antrum and adherent clot on ulcer bed at the lesser curvature near pre-pyloric region without active bleeding and ulcer was classified as forest 2b ulcer as shown in the figure. It is important to note that no intervention was performed given patient's last dose of Apexaban was within 24 hours. Patient remained hemodynamically unstable requiring increased dose of pressures and his hemoglobin was continuously dropping. CT and geo was repeated that showed active bleeding from gastric antrum near pylorus. Catheter angiography of ciliac artery localized contrast extravasation from supradudenal branch of right hepatic artery that was difficult to embolize. Therefore empiric embolization of gastro dudenal and gastroepiploic artery was performed. EGD was repeated that showed blood and clots in the gastric body and antrum. A 15 millimeter ulcer was seen at the anterior wall of the antrum. After washing the base of the ulcer active oozing of bright red blood was found from one centimeter protruding vessel at the anterior wall of the antrum as you can see here. This ulcer was classified as forest 2a ulcer that mimicked the appearance of forest 2b ulcer on prior EGD because of presence of clot on the tip of the vessel and no active bleeding. Epinephrine was injected in all four quadrants around the base of the ulcer that stopped bleeding. Ulcer base was examined after securing hemostasis for planning application of hemoclip. In this case the ulcer base was too large for application of hemoclips. Therefore we applied hemoclips around the vessel itself. A complete hemostasis was achieved with application of five clips. After application of each clip we examined the base of the ulcer and applied additional clips as needed. Patients hemodynamic status and hemoglobin were stabilized thereafter and follow-up EGD two days later revealed a clean base ulcer without evidence of bleeding. Clinical implications of case. This case illustrates endoscopic appearance of atypical prepyloric 1 centimeter visible vessel forest 2a ulcer mimicking a non-bleeding fibrin clot forest 2b ulcer. Endoscopic differentiation between forest 2a and 2b ulcers is important as rates of re-bleeding and management are different. Conclusions. A high index of suspicion is required when encountering atypical stigmata of recent hemorrhage that may alter management of bleeding ulcers. It also supports the practice of injecting epinephrine at the base of a clot and carefully washing the site to assess the presence of a visible vessel.

upper gastrointestinal bleeding

53-year-old man

atrial fibrillation

Apexaban

ulcer