Atypical gastric bleeding in a 55-year-old man, beyond the scope of treatment?

A 55-year-old man was admitted with a 3-week history of haematemesis with abdominal and back pain. He had a background of severe alcohol related pancreatitis 5 years previously and possible gastric varices. At presentation he was shocked (pulse 127, blood pressure 94/68, lactate 7.1 mM). Haemoglobin 8.0 g/L, platelet count 447 000/µL, liver function tests and coagulation were normal. After resuscitation and antibiotics he underwent oesophagogastroduodenoscopy in the Intensive Care Unit. Fresh blood was seen in the stomach, with thrombus adherent to an ulcer on a raised area of mucosa at the incisura (figure 1A). During therapeutic adrenaline injection, the needle was suspected of penetrating through the ulcer, and further therapy was halted. No free air was seen on erect chest X-ray. Subsequently, despite intravenous esomeprazole (8 mg/h), the patient continued to bleed and repeat oesophagogastroduodenoscopy was performed. Similar endoscopic features were seen and further submucosal injection of adrenaline performed and endoclips applied to the apparent source of bleeding at the incisura. After ongoing bleeding a CT angiogram was performed to assess the suspected submucosal lesion (figure 1B–D).