S4665 A Rare Cause of Massive Upper GI Bleed: Bleeding Gastric Diverticulum in an Elderly Patient

Introduction: Gastric diverticula (GD) are outpouchings of the stomach wall and are extremely rare, with an estimated prevalence of 0.01%–0.11%. They typically present between the ages of 50 and 70 and are usually asymptomatic, though they can cause varied abdominal symptoms. In rare cases, they can manifest as upper gastrointestinal bleeding (UGIB), which can be life-threatening. Case Description/Methods: An 84-year-old woman presented to the emergency department with a 1-week history of dark stools and fatigue. Her medical history included atrial fibrillation on anticoagulation and liver cirrhosis. She was a non-smoker and non-alcoholic, with no prior history of gastrointestinal bleeding. On examination, her abdomen was benign. Initially, she was hemodynamically stable with a hemoglobin of 11.5 g/dL. Stool occult blood was positive. She was admitted to telemetry for suspected GI bleeding and started on pantoprazole twice a day with serial complete blood count monitoring. Anticoagulation was held on admission. The following day, her hemoglobin dropped to 9.4 g/dL, and she developed massive hematemesis with blood clots, requiring intensive care unit transfer for active UGIB and impending hemodynamic collapse. Octreotide infusion was started for suspected variceal bleeding. Esophagogastroduodenoscopy revealed bright red blood in the stomach and a bleeding GD in the gastric fundus. Epinephrine was injected, and 5 endoscopic clips were placed to achieve hemostasis. The remainder of the endoscopic exam was unremarkable. She was closely monitored for further bleeding. On hospital day 3, anticoagulation was resumed after shared decision-making between the patient, GI, and cardiology teams. She was subsequently discharged in stable condition. Discussion: GD are extremely rare and usually asymptomatic, often discovered incidentally. However, they can occasionally present with bleeding. Our case is particularly noteworthy as it involved UGIB from a gastric diverticulum in an elderly patient with cirrhosis and atrial fibrillation on anticoagulation. Cirrhosis initially raised concern for variceal bleeding, but endoscopy identified an actively bleeding GD, underscoring the importance of thorough evaluation even in high-risk patients. Anticoagulation likely worsened the bleeding, posing a therapeutic dilemma in balancing bleeding risk with thromboembolic protection. This case highlights the importance of recognizing rare sources of bleeding in high-risk patients and the need for individualized management strategies that account for comorbidities and anticoagulation.