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.
The patient was a 67-year-old man, who arrived at the emergency department and referred with chronic epigastric pain and dyspepsia over the last 6 months and felt weakness. He suffered from diabetes mellitus type 2 and high blood pressure and took medications for both diseases. Currently, he reported that he periodically took nonsteroidal anti-inflammatory drugs (NSAIDs) for arthralgia during the last year, without taking inhibitor of gastric acid and he denied having black or bloody stools. Physical examination revealed only mild upper abdominal tenderness and the blood tests showed microcytic anemia with hemoglobin 10.1 g/L and iron deficiency with ferritin 13 ng/mL and iron 27 µg/dL. He underwent an esophagogastroduodenoscopy and colonoscopy as an outpatient due to gastrointestinal symptoms and microcytic anemia. The colonoscopy was normal, while the esophagogastroduodenoscopy revealed a normal esophagus, gastritis with erosions, a double pylorus and a normal duodenum. Specifically, an accessory channel connected the lesser curvature of the prepyloric antrum to the duodenal bulb and the endoscope was able to easily pass via both of the pyloric channels ().\nFurthermore, the Helicobacter pylori quick test proved positive, while histological examinations of gastric antrum and corpus showed chronic active gastritis in both of them and H&E stain revealed a large amount of Helicobacter pylori bacteria. Finally, the patient was treated successfully with concomitant therapy for the eradication of Helicobacter pylori (metronidazole 500 mg, amoxicillin 1g, clarithromycin 500 mg and lansoprazole 30 mg, twice a day for 10 days). The eradication was verified via a stool antigen test for Helicobacter pylori, 1 month after treatment. In addition, he took iron supplements, continues to take proton pump inhibitor once a day and has limited the use of NSAIDs. The symptoms were eliminated after a few weeks from the inception of therapy and the hemoglobin was normal after 5 months. Two years later, a follow-up endoscopy revealed that the bridge between the two channels was disappeared and there was only single large opening (). The stomach, duodenum and esophagus were normal. In addition, biopsies were taken from the gastric antrum and body, which showed chronic inactive gastritis, while H&E stain proved to be negative for Helicobacter pylori.