Gastric Diverticuli as a Cause of Obscure Gastrointestinal Bleeding

Abstract

Introduction: Gastric diverticuli are a rare but life-threatening source of obscure gastrointestinal bleeding. Their insidious and sometimes catastrophic presentation underlies the need for increased awareness and prompt management. A 75-year-old white male presented with symptoms of pre-syncope and dyspnea on exertion after multiple episodes of melena. He denied hematemesis, abdominal pain, dysphagia, or NSAID use. His co-morbidities included hypertension, diabetes mellitus, and atrial fibrillation. On admission, he was hemodynamically unstable with a tachycardia of 120 beats/minute and systolic BP of 60 mm of Hg. His physical examination was remarkable for melena on digital rectal examination. Laboratory tests revealed a Hb of 6.2, INR of 5.7, and an elevated BUN of 71. He was administered intravenous fluids, large-volume blood and plasma transfusions, and started on a pantoprazole infusion. On transfer to the ICU, he underwent an emergent upper endoscopy (EGD) with a large amount of retained blood and no obvious source of bleeding seen. The fundus was not adequately visualized due to an inability to clear the blood clots. An emergent Nuclear Medicine bleeding scan did not reveal active blood loss. He remained transfusiondependent and subsequently underwent a second EGD. This revealed the presence of a gastric fundal diverticulum (Figure 1 a,b), about 1 cm in diameter, with no other source of bleeding identified. The patient was referred for surgical evaluation; however, his clinical status gradually improved and he was discharged to the medical floor. Due to an often dramatic and potentially fatal presentation, gastrointestinal bleeding secondary to gastric diverticuli (GD) requires a high index of suspicion. Some reports have indicated vague symptoms of burning sub sternal pain or nonspecific abdominal discomfort preceding the presentation; however, patients are mostly symptom free. Prevalence ranges from 0.04% on barium contrast studies to 0.01-0.11% on endoscopy. Surgical resection is advocated in the presence of persistent symptoms or with complications such as persistent bleeding or a perforation.Figure 1