S4628 Multifactorial Duodenal Hemorrhage in a Patient With Diffuse Large B-Cell Lymphoma: Navigating Steroid-Induced Ulceration and Anticoagulation in the Setting of Sepsis

Introduction: Upper gastrointestinal bleeding (UGIB) is a potentially life-threatening emergency, especially in patients with complex comorbidities such as malignancy and venous thromboembolism. Although 80% of UGIB cases resolve with supportive care, patients with metastatic cancer, hemodynamic instability, or inpatient onset carry significantly higher mortality. We present a challenging case of UGIB in a patient with diffuse large B-cell lymphoma (DLBCL) and concurrent pulmonary embolism (PE), highlighting the complexities of management in the setting of competing risks. Case Description/Methods: A 74-year-old man with newly diagnosed DLBCL presented following a syncopal episode. He had recently initiated POLA-R-CHP chemotherapy. Imaging revealed a segmental pulmonary embolism and left soleal deep vein thrombosis. He was started on intravenous heparin. Within 72 hours, he developed melena and acute anemia (hemoglobin dropped from 9.0 to 5.6 g/dL). Heparin was discontinued, and a pantoprazole infusion was initiated. Computed tomography angiography revealed duodenal bleeding. The patient progressed to hemorrhagic shock requiring vasopressors and was concurrently septic, likely due to pneumonia. After stabilization with multiple transfusions (4 units packed red blood cells, 1 FFP, 1 platelet unit), an esophagogastroduodenoscopy (EGD) on hospital day 5 revealed 7 Forrest class III duodenal ulcers with nodularity, but no active bleeding. Given prior hemorrhagic shock, poor prognostic factors, and anticipated need for anticoagulation, PuraStat® topical hemostatic gel was applied generously. Biopsies were deferred to avoid provoking further bleeding. computed tomography imaging confirmed duodenal ulceration without mass or obstruction. H. pylori infection and gastrinoma were considered but deemed unlikely based on clinical context. Anticoagulation with apixaban 5 mg twice a day was resumed cautiously. Hemoglobin remained stable with no recurrent bleeding. An IVC filter was considered given rebleeding risk. Discussion: This case underscores the clinical tension between thrombotic risk and gastrointestinal bleeding in patients with hematologic malignancies. Steroid use, chemotherapy, sepsis, and anticoagulation likely contributed to multifactorial ulcer formation. Conservative endoscopic therapy with PuraStat®, proton pump inhibitor infusion, transfusion support, and delayed reintroduction of anticoagulation enabled clinical stability. Multidisciplinary coordination among gastroenterology, hematology, and critical care was crucial for optimal outcome in this high-risk, medically complex patient.