Introduction: Cytomegalovirus (CMV) gastropathy is a serious complication in solid organ transplant recipients. Endoscopically, these ulcers often present as large, deep, and friable lesions with diffuse oozing bleeding. Standard hemostatic techniques (clips, thermal coagulation) carry a high risk of tissue tearing or perforation in this setting. We present a case demonstrating the utility of hemostatic powder as a safe and effective primary therapy for high-risk CMV ulcers.

Case Description: A heart transplant recipient (1 year post-transplant) with a history of prior rectal CMV infection presented with melena and hemodynamic instability. Emergent gastroscopy revealed multiple ulcerations in the gastric body posterior wall.

The dominant lesion was a giant (>3 cm) ulcer with a characteristic "geographic" morphology, deep fibrin base, and irregular borders. An adherent clot was present, and upon washing, active diffuse oozing ("sheet-like") bleeding was observed from the ulcer edges. Given the extreme friability of the tissue and the extensive surface area of the bleeding, mechanical clipping was deemed technically unsafe, and thermal therapy posed a perforation risk. Consequently, hemostatic powder was applied as the primary modality, achieving immediate hemostasis without tissue contact.

Biopsies taken from the ulcer margins were positive for CMV on immunohistochemistry. The patient was treated with intravenous ganciclovir. A follow-up gastroscopy showed complete re-epithelialization of the ulcer, replaced by a flat, hyperplastic nodular scar, confirming therapeutic success.

Conclusion: This case highlights two critical points for the endoscopist. First, the "geographic" ulcer pattern in an immunocompromised patient is pathognomonic for CMV and mandates biopsy for immunohistochemistry, even in the setting of acute bleeding. Second, hemostatic powder represents an ideal therapeutic tool for these specific lesions, offering effective control of diffuse bleeding in friable, high-risk tissue where conventional mechanical or thermal methods may be hazardous.