Ms. Li suffered from a giant gastric ulcer with recurrent hemorrhage. Thanks to the painstaking efforts of multidisciplinary experts over 11 rounds of consultations lasting altogether 118 days, the etiology was finally revealed to be “cytomegalovirus gastritis with secondary vasculitis”.

Starting from June 2021, Ms. Li, 42, often felt abdominal pain after meals, accompanied by acid reflux and vomiting. The hospitals she visited did not cure her. She lost 13 kg in weight within the six months since the onset of disease.

Ms. Li then tried her luck at PUMCH. Sun Gang, professor from the Department of Gastroenterology, placed a nasojejunal feeding tube and treated her for gastric ulcer and tuberculosis. But the patient’s high fever persisted and abdominal pain was not relieved. She vomited blood and got hemorrhagic shock for four times in just half a month. She was brought back from the brink of death only after the Director of Gastroenterology, Yang Aiming, personally performed endoscopic hemostasis for her.

The Department of Gastroenterology organized several rounds of consultations and internal medicine grand rounds with relevant departments such as the Department of Infectious Diseases, Breast Surgery, Respiratory and Intensive Care Unit, Rheumatology, Endocrinology, Traditional Chinese Medicine, Clinical Nutrition, Radiology and Pathology. Considering that no evidence of tumor or cytomegalovirus infection was found on multiple biopsies and that the patient had tuberculous pleurisy and a severe systemic inflammatory response, it was presumed that she had secondary vasculitis triggered by tuberculosis. Therefore, the treatment strategy was adjusted to control the inflammatory response with systemic corticosteroids and immunosuppressants. The patient’s conditions improved slightly afterwards, with body temperature decreased and abdominal pain abated. But the huge gastric ulcer showed no signs of healing, and the probe into the underlying cause of the disease was still clueless. The worry and lack of understanding of the patient’s family added to the pressure on the medical team.

After a multidisciplinary consultation and thorough discussion with the patient’s family, Wu Dong, professor from the Department of Gastroenterology, and the family both decided to take a leap of faith and perform a surgery. Through another joint consultation with the Department of Gastroenterology, General Surgery, Rheumatology, Infectious Diseases and MICU, among others, a thorough surgical plan was formulated for Ms. Li. Then the team led by Xu Lai, Associated Professor of General Surgery successfully performed laparoscopic distal gastrectomy under general anesthesia for the patient. The ulcer was found during the operation to be more severe than what was seen under gastroscopy. The patient was very thin, in poor nutrition status, and the volume of the stomach had increased significantly. Her stomach was densely adhered to the abdominal wall, thus the stomach wall at the ulcer had become extremely thin. After the stomach wall was separated from the abdominal wall, a gastric wall defect of about 5 cm in diameter appeared.

The surgical specimen proved that Ms. Li was infected with cytomegalovirus (CMV), although her peripheral blood and endoscopic biopsy were negative for CMV. At this point, the cause of Ms. Li’s giant gastric ulcer finally came to light.

After the operation, Ms. Li received anti-CMV infection treatment. With careful care by doctors and nurses, she recovered well and was discharged from the hospital.

The team led by associate professor Xu Lai was performing the surgery on the patient

Professor Yang Aiming was performing endoscopic hemostasis on the patient

Written by Reporter Yan Xiaobo

Picture courtesy of the Department of General Surgery and the Department of Gastroenterology

Translated by Liu Haiyan

Edited by Zheng Weiyang and Wang Yao