Giant Gastric Ulcers: An Unusual Culprit

Abstract

Mycophenolate Mofetil (MMF) is routinely used immunosuppressant in solid organ transplantation is commonly associated with several gastrointestinal (GI) side effects. Here we present a case of giant gastric ulcer of 5 cm from MMF use post cardiac transplant. Case Description A 56-year-old male with history of severe ischemic cardiomyopathy post heart transplant was on immunosuppression with MMF, tacrolimus and prednisone for 5 months. He presented with severe epigastric pain and intermittent episodes of melena for 1 month. His pain radiated to back that is worsened with eating. Associated with loss of appetite, vomiting and 16-pound weight loss in 3 months. He never smoked, drank alcohol or used over the counter pain medications. He was profoundly anemic requiring blood transfusions. EGD performed demonstrated very large clean-based ulcer of 5 cm diameter in the body, smaller ulcer of 8 mm diameter in pre-pyloric region and 5-10 small aphthous ulcers in the gastric body and fundus. Gastric biopsies taken from the ulcer were negative for Helicobacter pylori, cytomegalovirus and malignancy. Flexible sigmoidoscopy revealed non-bleeding inflamed internal hemorrhoids. Consequently, MMF was discontinued and switched to azathioprine. He was treated with twice daily proton pump inhibitor therapy with resolution of abdominal pain, improved appetite and weight gain. Discussion MMF is well known for common GI side-effects such as nausea, diarrhea, vomiting, ulcers, abdominal pain and rarely gastrointestinal bleeding. Few studies reported 3 to 8% incidence of ulcer perforation and GI bleeding within 6 months. Risk of gastroduodenal erosions is nearly 1.83 times for MMF, with the highest lesions associated with MMFtacrolimus-corticosteroid combination treatment as seen in our patient. Hypothesis is that GI tract is vulnerable because of dependence of enterocytes on de novo synthesis of purines, which is disrupted by MMF. Typically, upper GI mucosal injuries of mucosal irritation leading to esophagitis, gastritis and/or ulcers are seen. Endoscopy is both diagnostic and therapeutic if bleeding gastric ulcers are noted. Minor complications improve with reduction of drug dose or use of enteric coated preparation if feasible. Discontinuation of the drug is main stay in the management of MMF related ulcer disease. Simple medical treatment with either H2-receptor antagonists, proton-pump inhibitors, coating agents, prostaglandins or combination has proven effective in most cases. Considering excellent results with medical management of ulcer, role of surgery is limited.

Rabeprazole inhibits inflammatory reaction by inhibition of cell pyroptosis in gastric epithelial cells

“…A standard triple therapy, including the proton pump inhibitors (PPIs) and antimicrobial agents, such as amoxicillin, clarithromycin, metronidazole, and levofloxacin, is widely used as the first-line regimen for treatment of Helicobacter pylori infection [1][2][3]. Helicobacter pylori is a microbial carcinogen of gram-negative bacteria, which has been believed to be associated with the development of chronic gastritis, peptic ulcer disease, and gastric cancer (GC), leading dysfunction of inflammation [4][5][6], such as gastric mucosa-associated lymphoid tissue lymphoma (MALT) [7][8][9].…”

A randomised controlled trial: effect of the meticulous nursing model on the treatment compliance and quality of life of patients with upper gastrointestinal bleeding

“…Upper gastrointestinal bleeding (UGIB), a common gastrointestinal disease, usually refers to gastrointestinal bleeding above the Treitz, occurring at the stomach, esophagus, duodenum, and biliary and pancreatic regions (1)(2)(3). Epidemiological studies have found that the mortality rate of this disease is as high as 25-30%, and mainly occurs in adults.…”

Clinical observation of magnesium aluminum carbonate combined with rabeprazole-based triple therapy in the treatment of helicobacter pylori-positive gastric ulcer associated with hemorrhage

“… 16 With the development of society and the changes in people’s lifestyles, patients with gastric ulcer bleeding account for the largest proportion of all gastric ulcer complications. 17 Its clinical symptoms include melena, hematemesis, and shock reaction in severe cases 18 , which seriously threatens the life and health of patients. Helicobacter pylori (H. pylori) is present in approximately 50% of the world’s population, with infection levels in developing countries reaching more than 70%.…”