Abstract Introduction Massive transfusion protocols (MTPs) remain vital in managing life-threatening hemorrhage, providing structured delivery of blood products while minimizing coagulopathy, acidosis, and hypothermia. Splenic artery perforation secondary to gastric ulcer disease is exceedingly rare and carries a high mortality rate without rapid surgical and resuscitative intervention. We present a case of survival after catastrophic upper gastrointestinal bleeding managed through early MTP activation, aggressive resuscitation, and emergent total gastrectomy with splenectomy. Case Description A 68-year-old bedbound woman with hypertension, arthritis, and cerebral palsy presented with hematemesis, hypotension (66/49 mmHg), and lactic acidosis (3.1 mmol/L). CT angiography revealed a small enhancing focus near the splenic artery. Initial endoscopy demonstrated a bleeding fundal ulcer with adherent clot managed endoscopically. Despite transient stabilization, she developed recurrent hematemesis with hemorrhagic shock requiring vasopressors and intubation. The massive transfusion protocol was activated. The patient received 15 units of packed red blood cells, 3 units of fresh frozen plasma, and 1 unit of cryoprecipitate, along with tranexamic acid, calcium, and active warming. Despite maximal medical support, ongoing hemodynamic instability necessitated emergent laparotomy. Intraoperative findings revealed a large posterior fundal ulcer that had eroded into the splenic artery, resulting in over 5 liters of intragastric and intraperitoneal bleeding. Total gastrectomy and splenectomy were performed, and the abdomen was left in discontinuity with radiopaque packing for staged management. Postoperatively, she required brief vasopressor support, stabilized hemodynamically, and was transferred to a tertiary care center for Roux-en-Y esophagojejunostomy reconstruction. She recovered with preserved organ function and was later discharged to a rehabilitation facility. Discussion This case illustrates a rare but catastrophic complication of peptic ulcer disease resulting in splenic artery perforation. Rapid activation of MTP and early surgical intervention were pivotal to survival. Balanced transfusion in a 1:1:1 ratio prevented worsening coagulopathy and supported end-organ perfusion during ongoing hemorrhage. The success of this case underscores the importance of protocolized multidisciplinary coordination between emergency, surgical, anesthesiology, transfusion, and critical care teams. Early recognition of refractory hemorrhagic shock, rapid initiation of MTP, and aggressive surgical control remain the cornerstone of survival. Moreover, this case highlights the need for vigilance in chronic NSAID users, where posterior gastric ulcers can silently erode into major vascular structures. Survival following splenic artery perforation and total gastrectomy is exceptionally rare, reflecting an extraordinary collaborative outcome. This abstract is funded by: None
Sinawe et al. (Fri,) studied this question.