Hematemesis Work-up & Treatment in a 60-Year-Old with Ulcerative Gastric Mass on OGD

Overview

STEP 1: IMMEDIATE RESUSCITATION & STABILIZATION

• Assess airway patency immediately - massive hematemesis risks aspiration
• If hemodynamically unstable or altered consciousness: early airway management (intubation), noting that RSI in an actively bleeding patient carries significant peri-intubation risk - use cardiovascular-stable agents (e.g., ketamine or etomidate) and aggressively resuscitate before intubating

• Insert two large-bore IV lines (16G or larger)
• Group & crossmatch, type and screen
• Start isotonic crystalloid resuscitation (normal saline) - but avoid over-aggressive resuscitation as this may worsen bleeding

• Transfuse packed red blood cells (pRBC) to maintain Hb ≥ 7 g/dL (threshold ≥ 9 g/dL for this 60-year-old if they have coronary artery disease or significant comorbidities)
• If massive bleeding is expected: activate massive transfusion protocol (1:1:1 ratio of pRBC : FFP : platelets)
• Correct coagulopathy: FFP if INR elevated; platelets if < 50,000/µL

STEP 2: INITIAL INVESTIGATIONS (Work-up)

Bloods

Bedside

• Nasogastric (NG) lavage: red blood or coffee-ground aspirate confirms active UGI bleeding when clinically uncertain
• ECG (baseline, especially in a 60-year-old)
• Urinary catheter + monitor urine output

Imaging (after initial stabilization)

• CXR: baseline, aspiration, perforation
• CT scan of chest/abdomen/pelvis with contrast - especially given the ulcerative gastric mass: this is essential for staging, assessing resectability, lymph node involvement, and metastases
• CT angiography if active arterial bleeding suspected and endoscopy unavailable

Risk Stratification

• Blood urea nitrogen
• Haemoglobin
• Systolic BP
• Heart rate
• Syncope, melena, liver disease, cardiac failure

• Albumin < 3.0 g/dL
• INR > 1.5
• Altered mental status
• Systolic BP < 90 mmHg
• Age > 65

STEP 3: ENDOSCOPIC MANAGEMENT (OGD Already Done - Next Steps)

Endoscopic Hemostasis (if active bleeding at the time of OGD)

1. Injection therapy - adrenaline/epinephrine (1:10,000) injected around the bleeding point
2. Thermal coagulation - multipolar electrocoagulation (MPEC), heater probe - applied with firm pressure; achieves hemostasis by co-aptive coagulation
3. Mechanical therapy - hemoclip application
4. Combination therapy - epinephrine injection + thermal or mechanical is superior to monotherapy alone for high-risk lesions (active arterial bleeding, non-bleeding visible vessel)

The Missing Biopsy - What to Do

"Biopsy should be performed even if gastric lesions appear benign endoscopically... Malignant lesions are often associated with an irregular ulcerated mass that protrudes into the lumen with wall deformity, and abnormal folds surrounding the ulcer crater with overhanging or irregular margins." - Yamada's Textbook of Gastroenterology, 7th ed.

"When a gastric ulcer has been detected endoscopically, biopsy is generally recommended in all cases to rule out malignancy... Larger ulcers and ulcers with irregular or heaped-up edges are more likely to harbor cancers." - Sabiston Textbook of Surgery

• Minimum 4-6 biopsies (ideally 7+) from all four quadrants of the ulcer edge
• Samples from the ulcer crater and surrounding mucosa
• Brush cytology may be added to increase diagnostic yield
• 7 biopsy specimens achieves >98% sensitivity for malignancy detection

STEP 4: PHARMACOLOGICAL TREATMENT

Proton Pump Inhibitor (PPI)

• Omeprazole 80 mg IV bolus, then 8 mg/hour infusion (or equivalent high-dose PPI)
• Indicated for non-variceal UGI bleeding (which this is, given the gastric ulcer/mass)
• High-dose IV PPI significantly reduces rebleeding rates, need for surgery, and mortality
• Reduces peptic ulcer rebleeding from up to 35% (medical therapy alone) to ~5% after endoscopic hemostasis
• Sabiston: "PPIs have a healing rate of 85% at 4 weeks and 96% at 8 weeks"

If Variceal Bleeding is Also a Concern (e.g., cirrhosis suspected)

• Octreotide (somatostatin analogue): 50 µg IV bolus then 25-50 µg/hour infusion
  • Note: in elderly patients (including this 60-year-old), begin at lower dose: 25 µg bolus and 25 µg/hour infusion
• Antibiotics: ciprofloxacin 400 mg IV or ceftriaxone 1 g IV if cirrhosis with UGI bleed (reduces infection risk and rebleeding)
• Terlipressin or vasopressin: vasoconstriction to reduce portal pressure

H. pylori Testing & Treatment

• All gastric ulcer patients should be tested for H. pylori
• Test via: rapid urease test (CLO test) at endoscopy biopsy, or urea breath test, or stool antigen (avoid serology if possible)
• If positive: triple therapy (PPI + amoxicillin + clarithromycin, or bismuth quadruple therapy)
• Note: PPIs render endoscopic H. pylori testing unreliable, so biopsy urease testing should ideally be done before starting PPI

STEP 5: MANAGEMENT OF THE ULCERATIVE GASTRIC MASS

1. Gastric adenocarcinoma (most common - must be excluded urgently)
2. Gastric lymphoma (MALT or diffuse large B-cell)
3. Gastrointestinal stromal tumour (GIST)
4. Benign peptic ulcer (less likely given the mass-like appearance)

"The tumour [gastric cancer] frequently bleeds, resulting in iron deficiency anaemia... Early satiety, bloating, distension and vomiting may occur... Weight loss can be profound."

Features on OGD Suggesting Malignancy

• Irregular, ulcerated mass protruding into lumen
• Heaped-up, rolled, or overhanging ulcer edges
• Wall deformity with abnormal converging folds
• Larger size (>2 cm increases malignancy risk)
• Location on lesser curve or pylorus

Investigations for Staging (once biopsy confirms or is pending)

1. CT chest/abdomen/pelvis - lymph node involvement, metastases (liver, peritoneum, lung)
2. Endoscopic ultrasound (EUS) - depth of tumour invasion (T-staging), perigastric lymph nodes
3. PET-CT - distant metastases
4. Staging laparoscopy - peritoneal deposits (often not visible on CT)
5. Tumour markers: CEA, CA 19-9, CA 72-4

Treatment (if Gastric Cancer Confirmed)

• Resectable disease: gastrectomy (total or subtotal depending on location) + D2 lymphadenectomy
  • Neoadjuvant chemotherapy (e.g., FLOT or FOLFOX) followed by surgery improves survival
• Advanced/metastatic disease: palliative chemotherapy, immunotherapy (if MSI-high or HER2+), supportive care
• Ongoing bleeding from tumour: endoscopic hemostasis as bridge; angiographic embolization; palliative radiotherapy for refractory tumour bleeding

STEP 6: ESCALATION IF ENDOSCOPY FAILS

• Interventional radiology: transcatheter arterial embolization (TAE) - for persistent non-variceal bleeding not controlled endoscopically
• Surgery: emergency laparotomy if all other modalities fail
  • Subtotal or total gastrectomy for non-variceal bleeding from the stomach
  • Emergent surgical consultation should be sought early in case of uncontrolled bleeding

STEP 7: DISPOSITION & MONITORING

• ICU admission for this high-risk 60-year-old (age >60 + active hematemesis + hemodynamic instability + mass lesion)
• Monitor:
  • Haemoglobin every 4-6 hours initially
  • Vital signs, urine output, lactate
  • Serial abdominal exams
• Continue high-dose IV PPI for at least 72 hours
• Repeat OGD within 24-72 hours if rebleeding occurs or if stable and biopsy still needed

Summary Algorithm

Hematemesis in 60-year-old + Ulcerative Gastric Mass on OGD
│
├── IMMEDIATE: Resuscitate → 2 large-bore IVs, crossmatch, fluids/blood
│
├── INVESTIGATIONS: FBC, coagulation, U&E (BUN:Cr ratio), LFTs, imaging
│
├── ENDOSCOPY: Hemostasis if active bleeding (Forrest classification)
│   └── HIGH-DOSE IV PPI (omeprazole 80mg bolus → 8mg/hr infusion)
│
├── BIOPSY: Repeat OGD urgently - minimum 4-7 biopsies from ulcer edges/base
│   ├── H. pylori testing (CLO test)
│   └── Histopathology to exclude malignancy
│
├── STAGING: CT chest/abdomen/pelvis; EUS; tumour markers; staging laparoscopy
│
└── DEFINITIVE TREATMENT:
    ├── Benign ulcer → H. pylori eradication + PPI + lifestyle changes
    └── Malignancy → Oncology/surgery MDT → Staging-directed treatment

Critical clinical point: The absence of biopsy from a gastric ulcerative mass in a 60-year-old is a significant management gap. Repeat endoscopy with multiple biopsies (at least 4, ideally 7) must be planned as a matter of urgency once the patient is haemodynamically stable. Gastric cancer presenting as an ulcerative mass is a serious possibility - early histological diagnosis determines all subsequent management.