An Unusual “PPI-Refractory” Symptomatic Gastric Ulcer Successfully Treated with Corticosteroids and Azathioprine: Eosinophilic Mural Ulcer

Abstract

A 23-year-old female was evaluated for chronic abdominal pain and iron deficiency anemia. She was initially diagnosed with peptic ulcer disease and was treated with a proton pump inhibitor (PPI). An initial upper endoscopy demonstrated a large antral gastric ulcer. Biopsy showed mixed inflammatory cell infiltration and no Helicobacter pylori organisms were seen. However, she continued to have rather severe epigastric pain requiring narcotic analgesics despite continuous aggressive therapy with a PPI. Past medical history included asthma. Physical examination was unremarkable except for epigastric tenderness. Laboratory studies showed a hemoglobin of 8 g/dl, MCV 69 fL, white blood cell count 6,100/uL with 11% eosinophils. Abdominal imaging studies looking for other causes of her pain were negative. The possibility of noncompliance with PPI treatment or OTC NSAID use was raised. However, repeat endoscopy in June 2007 revealed a larger prepyloric penetrating ulcer and an adjacent smaller antral ulcer. Multiple biopsies were obtained and demonstrated abundant eosinophilic infiltration. Serum gastrin was normal. Colonoscopy was unremarkable. The diagnosis of eosinophilic mural gastric ulcer was made and she was started on prednisone 50 mg daily concomitantly with Azathioprine 50 mg to be increased to 100 mg daily in addition to a proton pump inhibitor. Dramatic symptomatic and clinical improvement occurred shortly after medical therapy was initiated. Eosinophilic gastric ulcer is believed to be a rare/localized manifestation of the entity of eosinophilic gastroenteritis. This case uniquely illustrates (1) a refractory large, gastric ulcer with a smaller adjacent ulcer. (2) clinically manifesting as persistent problematic upper abdominal pain and iron deficiency anemia, and (3) immediate improvement with corticosteroid/immune modulator therapy without the need for surgical intervention. Clinicians and Gastroenterologists should suspect this readily treatable entity in cases of ulcers with unusual clinical behavior.