The Importance of Unfettered Gastric Motility

Question: A 46-year-old woman presented with a 3-week history of worsening dyspnea on exertion. Her past medical history was significant for poorly controlled type 2 diabetes with prior treatment for gastroparesis and iron-deficiency anemia. Pertinent medications included metformin, daily aspirin, esomeprazole, and iron supplementation. Physical examination revealed a pale woman in no acute distress. Her abdomen was soft without tenderness to palpation. Rectal examination revealed melena. Laboratory results showed severe anemia with a hemoglobin of 5.3 g/dL and a hematocrit of 18.2%. The iron profile revealed an iron of 46 μg/dL, and transferrin saturation of 11.7%. The patient was stabilized with IV fluid hydration and IV proton pump inhibitor; she was given 2 units of packed red blood cells. An upper endoscopy was performed. An acute gastric ulcer was noted within a dependent portion of the fundus. The ulcer was not actively bleeding and had an abnormal shiny metallic quality, as if it were stained (Figure A). The apparent staining did not wash with repeated flushing. Biopsies were taken from the edge of the ulcer (Figure B, C). What is the etiology of this ulcer? What conditions predispose a patient to this type of ulcer?

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