Clin Endosc > Volume 56(2); 2023 > Article
CME for
KSGE members
Kosasih, Telisinghe, Lim, Metussin, Asli, and Chong: Chronic non-healing gastric ulcer in a patient with poorly controlled diabetes mellitus


A 46-year-old man with non-replicative chronic hepatitis B infection and poorly controlled diabetes mellitus (glycosylated hemoglobin (HbA1c), 14.2%) with microalbuminuria, hypertension, and dyslipidemia, was referred for investigation of his chronic dyspepsia. Upper gastrointestinal endoscopy performed at another center showed a large excavating ulcer at the incisura (measuring 4 cm) with a firm necrotic base. Biopsies from the margin of the ulcer were negative for malignancy but positive for chronic gastritis, intestinal metaplasia, and Helicobacter pylori. It also showed Candida spores and possible hyphae elements. Repeat evaluation was recommended. The patient was administered H. pylori eradication therapy with 10 days of omeprazole 20 mg twice daily, amoxicillin 1 g twice daily, and clarithromycin 500 mg twice daily followed by maintenance omeprazole (20 mg twice daily). Due to the concern for underlying malignancy, a computed tomography (CT) scan was performed and showed a thickened lesser curve (thickest, 2.5 cm) with peri-gastric, celiac, and retroperitoneal lymphadenopathies (Fig. 1). The largest lymph node measured 1.5 cm. The remaining organs were normal. A repeat endoscopy two months after H. pylori eradication therapy showed a non-healing of the ulcer with a less necrotic base (Fig. 2). It was not possible to properly visualize the ulcer base because of its location and depth. Biopsies were obtained from the ulcer’s margins and base. Results from the biopsies were again negative for malignancy, but this time the diagnosis was confirmed (Fig. 3). Furthermore, staining for H. pylori returned negative results.
What is the most likely diagnosis?


Conflicts of Interest
The authors have no potential conflicts of interest.
Author Contributions
Conceptualization: all authors; Data curation: SK, VHC, PUT, KCL; Writing–original draft: SK, VHC, PUT, KCL; Writing–review & editing: all authors.

Fig. 1.
Axial (A) and coronal (B) contrast-enhanced computed tomography images show diffuse thickening of the stomach wall, mainly of the submucosal layer along the lesser curvature (arrowheads), with reactive peri-gastric adenopathy (arrows).
Fig. 2.
Endoscopic findings. An incisura showing edematous mucosa with a deep penetrating ulcer with narrowing of the gastric lumen (A), and mild erosions in the otherwise normal antrum (B).
Fig. 3.
(A) Hematoxylin and eosin stain of gastric biopsy showing fungal hyphae amongst necrotic tissues (×200). (B) Grocott methenamine silver stain showing the fungal hyphae more clearly (×200).


1. Roden MM, Zaoutis TE, Buchanan WL, et al. Epidemiology and outcome of zygomycosis: a review of 929 reported cases. Clin Infect Dis 2005;41:634–653.
crossref pmid
2. Patel A, Kaur H, Xess I, et al. A multicentre observational study on the epidemiology, risk factors, management and outcomes of mucormycosis in India. Clin Microbiol Infect 22020;26:944–950.
3. Didehdar M, Chegini Z, Moradabadi A, et al. Gastrointestinal mucormycosis: a periodic systematic review of case reports from 2015 to 2021. Microb Pathog 2022;163:105388.
crossref pmid
4. Sharma D. Successful management of emphysematous gastritis with invasive gastric mucormycosis. BMJ Case Rep 2020;13:e231297.
crossref pmid pmc
5. Mittal T, Pulle MV, Dey A, et al. Gastric mucormycosis presenting as gastrocolic fistula: a rare entity. Indian J Surg 2016;78:511–512.
crossref pmid pmc pdf
PDF Links  PDF Links
PubReader  PubReader
ePub Link  ePub Link
XML Download  XML Download
Full text via DOI  Full text via DOI
Download Citation  Download Citation
Related article
Editorial Office
Korean Society of Gastrointestinal Endoscopy
#817, 156 Yanghwa-ro (LG Palace, Donggyo-dong), Mapo-gu, Seoul, 04050, Korea
TEL: +82-2-335-1552   FAX: +82-2-335-2690    E-mail:
Copyright © Korean Society of Gastrointestinal Endoscopy.                 Developed in M2PI
Close layer