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Abstracts: CLINICAL VIGNETTES/CASE REPORTS - STOMACH

Candida-Associated Peptic Ulcer Disease in the Setting of Acute Upper Gastrointestinal Bleeding: A Rare Entity?

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Penumetsa, Karthik MD; Pawa, Swati MD

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American Journal of Gastroenterology: October 2014 - Volume 109 - Issue - p S270-S271
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Introduction: There remains very limited literature on Candida associated infection of the gastrointestinal tract outside the esophagus especially in relation to the stomach. Candida-associated gastric ulcer typically occurs in immunocompromised hosts or in patients who have had surgery for peptic ulcer disease but seldom in healthy individuals.

Case Report: A 76-year-old male with history of kidney disease and hypertension was admitted for a diffuse rash covering most of his body. Biopsy was consistent with erythema multiforme. No obvious etiology or drug exposure was evident. Patient was noted to have melena and anemia with Hemoglobin of 6.2 and required transfusions. Upper endoscopy (UE) was performed and showed white plaques and brushings in the esophagus consistent with Candida. A large 1.5 cm ulcer with a blood clot was seen in the funds which was injected with epinephrine and hemo clipped. No active bleeding was seen. There were several, raised, ulcerated lesions with central dark spots with thick surrounding exudates averaging 5-6 mm in size involving the body and antrum. The biopsies from all these ulcers revealed chronic active gastritis with ulceration and Candida species identified by GMS special stain. However, no Helicobacter pylori or intestinal metaplasia or malignancy was identified. He was treated with IV fluconazole along with high dose omeprazole, but he continued to have refractory anemia with melena. Patient underwent an IR embolization of left gastric and splenic arteries, with control of bleeding. Repeat UE showed healing of previously noted ulcers. He was eventually discharged on hospice after suffering pulmonary complications secondary to his underlying pneumonia.

Discussion: Unlike the classical plaque like appearance of the esophageal candidiasis on endoscopy, candida involvement of the stomach is typically more ulcer like and is typically associated with a complicated course, such as abdominal pain, nausea, emesis or fevers. Our patient had significant Candida - associated ulcer bleeding which happens to be a rarely reported complication. The natural history of Candida gastric ulcer is yet to be elucidated and current literature shows mixed results as to whether fungal colonization or invasion of gastric ulcer has any effect on healing of the ulcer.

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