P0888 - Rethinking Biopsy in Gastric Ulcers: A Rare Aggressive Neuroendocrine Tumor Initially Overlooked

Aftab Sharif, MD¹, Umer Farooq, MD², Marium Faiz, MD¹, Timothy Brotherton, MD², Mike Giacaman, MD²
1Southeastern Regional Medical Center, West Burlington, IA; 2Saint Louis University, Saint Louis, MO

Introduction: Gastric ulcers are frequently attributed to non-steroidal anti-inflammatory drugs (NSAIDs) and Helicobacter pylori infection, with malignancy being an uncommon but critical etiology. Endoscopic features guide risk stratification: malignant ulcers often display irregular, thickened margins and nodular or fused folds, whereas benign ulcers are characterized by smooth, regular edges and a flat base. Current guidelines recommend biopsying ulcers with malignant features or those in high-risk patients, but no consensus exists for reassuring-appearing ulcers in low-risk individuals.

Case Description/

Methods: A 52-year-old woman with chronic NSAID use for osteoarthritis, hypertension, and obesity presented with several weeks of abdominal pain and melena, culminating in hematemesis. Laboratory evaluation revealed acute anemia (hemoglobin 7.5 g/dL). Initial esophagogastroduodenoscopy (EGD) demonstrated a 1.5 cm gastric cardia ulcer with a visible vessel that bled upon manipulation; hemostasis was achieved with epinephrine injection, bipolar cautery, and clipping. The ulcer appeared benign, and no biopsy was obtained. Four weeks later, the patient returned with recurrent symptoms; abdominal CT revealed an 11.2 × 10.4 × 11.6 cm left upper quadrant mass. Repeat EGD showed two cratered ulcers at the prior site, prompting biopsy. Histopathology identified small cell carcinoma. Subsequent PET-CT and brain MRI excluded extra-abdominal primary or metastatic disease. A diagnosis of primary gastric neuroendocrine carcinoma was established, and systemic chemotherapy was initiated.

Discussion: This case highlights the limitations of endoscopic appearance and traditional risk stratification in detecting rare, aggressive malignancies. We advocate for a low threshold to biopsy all gastric ulcers—even those appearing benign in low-risk patients—to facilitate earlier diagnosis and improve clinical outcomes.

Disclosures:
Aftab Sharif indicated no relevant financial relationships.
Umer Farooq indicated no relevant financial relationships.
Marium Faiz indicated no relevant financial relationships.
Timothy Brotherton indicated no relevant financial relationships.
Mike Giacaman indicated no relevant financial relationships.

Aftab Sharif, MD¹, Umer Farooq, MD², Marium Faiz, MD¹, Timothy Brotherton, MD², Mike Giacaman, MD². P0888 - Rethinking Biopsy in Gastric Ulcers: A Rare Aggressive Neuroendocrine Tumor Initially Overlooked, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.