A male 59-year-old patient was admitted to the Dr. Soetomo General Hospital with hematemesis and melena. The patient complained of hematemesis for 6 h before admission. He vomited three times with an amount of 200–300 mL and had lower abdominal pain. Defecate black liquid twice since 6 h before admission with a very bad smell. The patient complained of dizziness accompanied by nausea and had no appetite since 5 days. There had been shortness of breath when performing heavy activity, reduced when resting and absence of fever.\nThe patient had a history of diabetes mellitus since 3 years. He was under insulin and oral medication but irregularly. History of hypertension, heart, lung, and kidney diseases was denied. There was a history of consuming medicinal herbs for myalgia. The patient consumed it every day. He felt weak when he did not drink. He used this drug for the past 5 months. Psycho-social history: he works as a construction worker and is smoking three packs a day since youth.\nOn physical examination, it was found with compos mentis GCS 456 that his blood pressure was 125/75 mm Hg, heart rate was 96 ×/min regular, strong pulse, adequate content, respiratory rate was 20 ×/min, the axillary temperature was 36.5°C, and SpO2 was 99% of free air. The examination of head and neck conjunctiva anemic was present, no jaundice, no cyanosis, no dyspnea, no enlarged lymph nodes, jugular venous pressure does not increase. The thorax was normal, the abdomen appeared flat and there was no palpable mass, liver and spleen enlargement were not palpable, he had normal bowel sounds, and abdominal pain in the umbilical region. Extremities were warm, dry acral, capillary refill time <2 s. No edema was found on both legs.\nLaboratory tests showed that his Hb was 8.3 g/dL, hematocrit was 23.6%, MCV 78.1; MCH 27.5; MCHC 35.2; platelets were 356,000 mm3, leukocytes were 14,369 mm3, neutrophils were 79.1%, lymphocytes were 14.5%, sodium was 132 mmol/L, potassium was 4.4 mmol/L, chloride was 106 mmol/L, HbA1C was 11.2%, random blood sugar was 202 mg/dL, SGOT was 16 U/L, SGPT was 27 U/L, blood urea nitrogen (BUN) was 28 mg/dL, serum creatinine was 1.14 mg/dL, and albumin was 3 g/dL. The examination of chest radiograph showed normal heart and lungs.\nThe patient was treated with a B1 soft diet 2,100 kcal/day, infusion of NaCl 0.9% 1,500 mL in 24 h i.v., injection of omeprazole 40 mg every 8 h i.v., sucralfat syrup 15 mL every 8 h orally, novorapid injection 4 units every 8 h sc ac 15 min, transfusion of packed red cells (PRC) 1 bag/day until Hb >10 g/dL, metoclopramide 10 mg every 8 h i.v., amlodipin 10 mg every 24 h orally, lactulac syrup 15 mL every 8 h orally, Ceftriaxon 1 g every 12 h i.v., and paracetamol 500 mg every 8 h orally.\nThe patient had been given PRC transfusion until Hb reached 10.3 g/dL, and the upper gastrointestinal EGD showed that the cause of bleeding to this patient was a gastric ulcer which was suspected and caused by consumption of medicinal herbs. At EGD, double pylorus was accompanied by giant white ulcer with a partially covered in clotting without any sign of active bleeding. It could be concluded that there was a double pylorus with giant ulcer, Forrest IIb (Fig. ).\nAfter 1 week of treatment at Dr. Soetomo General Hospital, the patient's complaints were improved and he had no nausea nor vomiting, there were no hematemesis and melena, and his appetite was improved. The patient was discharged from hospital. Planning therapy was B1 soft diet 2,100 kcal/day, omeprazole 20 mg every 12 h per oral, sucralfat syrup 15 mL every 8 h orally, novorapid injection 4 units every 8 h sc ac 15 min, amlodipin 10 mg every 24 h orally. Biopsy revealed chronic inactive gastritis, and no H. pylori was detected. The patient underwent checkup at the Gastroenterology department after 1 week of hospital discharge with complaints of decreased appetite, abdominal pain, and no nausea and received sucralfate syrup and lansoprazole orally.
A 65-year-old female with history of chronic alcohol use was hospitalized for sudden onset of hematemesis. She also reported few days of nausea and vomiting associated with worsening ascites. She denied any significant past medical history except for a ruptured ovarian cyst at age of 30 years that required emergent surgery. Patient had a long history of alcohol use (two glasses of vodka daily) for over 10 years. Physical exam showed scleral icterus, there was mild abdominal distention with epigastric tenderness, no hepatosplenomegaly was noted. No signs of encephalopathy or asterixis were seen. Blood test showed hemoglobin 10.4 × 10 g/dL, white blood cell count of 7.7 × 103 cells/µL and platelet count of 190 × 103 cells/µL. Her prothrombin time and international normalized ratio (INR) were elevated at 1.4 and 14.3 s, respectively. Liver function test showed aspartate transaminase 140 U/L, alanine transaminase 29 U/L, alkaline phosphatase 332 U/L, total bilirubin 9.6 mg/dL (direct 7.4 mg/dL, indirect 2.2 mg/dL). Few hours after admission, she developed an episode of hematemesis with drop in hemoglobin to 7.7 g/dL. Emergent endoscopy showed a non-bleeding 2 cm prepyloric gastric antral ulcer (). Biopsy of the ulcer base was negative for malignancy or H. pylori.\nFollow-up endoscopy at an interval of 6 weeks showed a healing prepyloric antral ulcer with mild portal hypertensive gastropathy (). Patient had a repeat endoscopy at 4 months for persistent nausea and vomiting which again showed a healing antral ulcer. She continued to drink alcohol and was intermittently followed by her the primary care physician. She also reported daily NSAID use for abdominal pain and nausea. She had multiple emergency department (ED) visits for the same complaints and underwent repeat endoscopy which showed a duodenal ulcer (). She was managed with pantoprazole twice daily and was advised to avoid NSAIDs and alcohol. She also underwent extensive workup for recurrent nausea and vomiting which were all unremarkable. Systemic disorders including but not limited to neurological cause, adrenal, parathyroid and diabetes were also ruled out.\nShe again presented to the ED for worsening nausea and vomiting associated with upper abdominal pain. Endoscopy, now 7 years from the discovery of the initial lesion, showed a GDF. The prepyloric antral ulcer had fistulized into the duodenal bulb creating the appearance of a double pylorus (). Biopsy of the ulcer base was again negative for malignancy or H. pylori. H. pylori stool antigen and serum H. pylori antibody test were also negative. She was discharged on oral proton pump inhibitor and has been followed up with gastroenterology for management of Laennec’s cirrhosis. With more frequent outpatient follow up, alcohol abstinence and use of acid-suppression medication, she had gradual improvement in her symptoms in about 1 - 2 months.