Anatomy Thorax Abdomen · Year 1 · from Anatomy Thorax Abdomen
Case 1: Bleeding Posterior Gastric Ulcer
Clinical Presentation
A 62-year-old male with a history of chronic NSAID use for osteoarthritis presents with melena for 3 days and an episode of hematemesis this morning. He reports epigastric pain that typically occurred 2-3 hours after meals and was partially relieved by antacids. Over the past week, the pain has worsened and now radiates to his back. He appears pale with blood pressure of 95/60 mmHg and heart rate of 115 beats per minute.
After fluid resuscitation, upper endoscopy reveals a 2 cm ulcer on the posterior wall of the gastric body near the lesser curvature with a visible vessel at the base that is actively spurting blood. Epinephrine injection and hemoclip placement achieve initial hemostasis. However, the patient rebleeds 12 hours later with hemodynamic instability. Interventional radiology performs angiography demonstrating extravasation from the left gastric artery, which is successfully embolized. The patient stabilizes and is treated with high-dose proton pump inhibitors.
Radiographic Findings
Image: Endoscopic view of a gastric ulcer showing mucosal defect with surrounding inflammation. Posterior ulcers may erode into adjacent vascular structures. Source: Wikimedia Commons, CC BY-SA 3.0.
Key Anatomical Points
- The stomach receives its blood supply entirely from the celiac trunk through four main arteries along the curvatures
- The left gastric artery (from celiac trunk) and right gastric artery (from hepatic artery proper) supply the lesser curvature
- Posterior gastric ulcers on the lesser curvature may erode into the left gastric artery or splenic artery
- The stomach bed includes the pancreas, which lies directly posterior to the stomach, separated only by the lesser sac
Key Learning Points
- Anterior ulcers tend to perforate into the peritoneal cavity; posterior ulcers tend to erode into vessels or the pancreas
- Pain radiating to the back suggests posterior penetration into the pancreas
- The rich anastomotic blood supply of the stomach makes it resistant to ischemia but explains the potential for significant hemorrhage
- Gastric lymphatic drainage follows four zones that all ultimately drain to the celiac nodes