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

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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?
 

NOTES

Conflicts of Interest
The authors have no potential conflicts of interest.
Funding
None.
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).
ce-2022-203f1.jpg
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).
ce-2022-203f2.jpg
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).
ce-2022-203f3.jpg

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