Case report
A 72-year-old female with a history of consumption of nonsteroidal
anti-inflammatory drugs for back pain was presented to our hospital for
melena and shock by the helicopter emergency medical service. The
patient had a history of atrial fibrillation and hypertension, for which
she was receiving rivaroxaban (10 mg/day) and carvedilol (10 mg/day).
During the emergency medical flight, the patient’s blood pressure was
49/30 mmHg and her heart rate was 50 beats per minute (bpm). The patient
received an intravenous transfusion of crystalloid fluid and tracheal
intubation in transit to the hospital. Upon arrival at our emergency
department, the patient’s vital signs and laboratory results included:
heart rate, 60 bpm; blood pressure, 95/44 mmHg; and hemoglobin, 4.0
g/dL. The patient received a transfusion of red blood cells and
fresh-frozen plasma for the treatment of anemia. Subsequent changes in
her vital signs and laboratory results, and the transfusion volume
administered, are shown in Figure 1. The patient underwent upper
gastrointestinal endoscopy; however, a lesion was not identified with
this technique due to profuse hemorrhage from the posterior wall of the
stomach. Consequently, contrast-enhanced computed tomography (CT) was
performed and showed the presence of free air in the abdominal cavity
and a large amount of extravasated fluid in the gastric lumen (Figure
2); thus, we decided to perform surgery to achieve hemostasis. Following
CT, the patient developed shock. We inserted a 7-French sheath into the
right femoral artery using the Seldinger technique. Then, a REBOA
catheter (RESCUE™ balloon catheter; Tokai Medical Products, Aichi,
Japan) was advanced to the distal thoracic aorta. Although the patient’s
blood pressure had decreased immediately prior to surgery, we were able
to control her blood pressure and the intragastric hemorrhage by
completely occluding the aorta with balloon inflation using the REBOA
technique. During the surgery, a circular transmural ulcer with a
diameter of 30 mm was found in the posterior wall of the stomach, and a
pyloric gastrectomy was performed (Figure 3). Active hemorrhage from the
splenic artery resumed after the endovascular balloon was deflated;
therefore, the ulcer was closed with sutures to achieve hemostasis. The
patient was admitted to the intensive care unit (ICU) due to the
development of coagulopathy and required open abdominal management to
evaluate blood flow in the gastric remnant. Subsequently, the patient’s
vital signs stabilized. A Roux-en-Y reconstruction procedure was
performed on the second day of hospitalization. The patient was
discharged from the ICU on the third day of hospitalization and was
discharged from the hospital on the 29th day of hospitalization without
organ dysfunction.