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.