This 61 year old lady was referred for evaluation of melena and a hematocrit of 21%. She has a past medical history of peptic ulcer disease, a positive H. pylori serology, and currently takes a baby aspirin each day. In the prepyloric antrum, this acute ulceration is seen at 11 o'clock to the pylorus. The tissue surrounding the ulcer is edematous. The ulcer base is flat with a single red spot which prognostically is associated with a 5-9% risk of rebleeding within the next 72 hours. The decision here was to treat with aggressive medical therapy and no endoscopic intervention. The patient did well with no further bleeding and was subsequently discharged. On biopsy, her CLO test was postive, indicating active Helicobacter pylori infection for which she was treated as an outpatient. As with duodenal ulcers, the prevalence of gastric ulcer associated H. pylori infection ranges from 65-95% and it is likely that H. pylori eradication in this patient will significantly reduced the likelihood of ulcer recurrence.
Peter B. Kelsey, M.D., Harvard Medical School, Massachusetts General Hospital