He was admitted to the hospital, resuscitated with several liters of crystalloid solution, transfused two units of packed red blood cells and placed on a continuous intravenous proton pump inhibitor infusion. Upper endoscopy was performed on hospital day three and five, both of which revealed the presence of a large, multi-lobulated tumor within the gastric lumen (Fig 1). The mass showed several areas of deep ulceration and continuous hemorrhage. The first endoscopy revealed a friable Inhibitors,research,lifescience,medical mass within the stomach,

which contained multiple areas of active hemorrhage. Several biopsies were taken and epinephrine was injected in an attempt to control bleeding. The patient was given two additional units of packed red blood cell BLZ945 transfusions and intravenous crystalloid solution. Upon repeat endoscopy 72 hours later, uncontrollable, spontaneous bleeding was noted from several ulcerated areas and the patient became hemodynamically unstable. At this point, Inhibitors,research,lifescience,medical the procedure was aborted, the patient was rapidly intubated and taken to the ICU for stabilization. The estimated blood loss for both endoscopies was approximately one liter of blood.

Figure 1. Upper endoscopy revealed the presence of a large, Inhibitors,research,lifescience,medical ulcerated, multi-lobulated mass (arrow) within the gastric lumen. The mass showed evidence of profuse hemorrhage (two arrows), which was temporized by epinephrine injection. On hospital Inhibitors,research,lifescience,medical day six the patient underwent a CT scan which confirmed the presence of a 10 cm × 10 cm multi-lobulated mass within the lumen of the stomach which was abutting the tail of the pancreas (Fig 2).

Foci of central necrosis were observed on one side of the lesion but there was no evidence of obvious metastatic disease. The next morning, he was taken to the operating room for exploration. Intraoperatively, a large mass involving the posterior Inhibitors,research,lifescience,medical wall of the stomach and the lesser sac was identified. There were multiple areas of profuse hemorrhage along the surface of the tumor. Surgery was initially attempted laparoscopically, but had to be converted to a laparotomy in order to safely separate the mass from the anterior surface of the pancreas and adjacent retroperitoneum. This separation was performed bluntly in order to gain control of the ongoing hemorrhage. Since the lesion extended superiorly Molecular Cell towards the gastroesophageal junction, a thoracoabdominal incision was made to obtain a sufficient proximal margin. Ultimately, the patient underwent a total gastrectomy, roux-en-Y esophagojejunostomy and feeding jejunostomy tube placement. A total of 2.5 liters of blood was lost intraoperatively and the patient was given six units of packed red blood cells and four units of fresh frozen plasma during surgery. Frozen section diagnosis was consistent with invasive adenosquamous cell carcinoma. Upon final pathological examination, the tumor was conclusively determined to be of pancreatic origin.