A peptic ulcer is defined as an erosion of the gastric or duodenal mucosa that extends through the muscularis mucosa. Helicobacter pyloriAssociated gastritis and ingestion of nonsteroidal anti-inflammatory drugs (NSAIDs) are the two most common causes of peptic ulcers. [1]. Other common causes are smoking, stress, foreign bodies, caffeine intake, and trauma. [1,2]. Kissing ulcers are a pair of ulcers facing each other on opposite walls of the stomach or duodenum. [2]. Although common in the duodenum, kissing ulcers of the stomach have been rarely reported in the literature. We present a rare case of gastric kiss ulcers secondary to ibuprofen (NSAID) intake.
An 85-year-old woman presented to the emergency room with new-onset hematemesis for one day. She had three episodes of hematemesis with no history of melena. She was a known hypertensive patient for 20 years, who was well controlled on amlodipine once daily. She also had age-related osteoarthritis, which had worsened in the last week, and she had been taking ibuprofen tablets twice a day (without a prescription) for the last five days. She had no history of jaundice, smoking, alcohol abuse, or trauma. She had no history of NSAID analgesic use.
At presentation, his hemodynamics were stable. His physical examination was normal. Upper gastrointestinal endoscopy revealed two ulcers in the middle of the body of the stomach, on the anterior and posterior walls, facing each other. They were 3×2 cm and 1×2 cm in size, respectively, with a detached base and without active bleeding, surrounded by normal gastric mucosa (Figure 1A). The anterior gastric wall ulcer was Forrest class IIc and the posterior wall ulcer was Forrest class III. The rapid gastric mucosal urease test was negative. Biopsies taken from both ulcers were negative for malignancy and H. pylori (Figure 1 B). Being the intake of NSAIDs the only identified risk factor, they were classified as Johnson’s type V ulcers.
He was advised to discontinue ibuprofen and treated conservatively with oral proton pump inhibitors. Repeat endoscopy after one month showed healing ulcers with surrounding normal mucosa (Figure two).
Peptic ulcer disease (PUD) is a heterogeneous disease caused by an imbalance between mucosal protective factors such as mucosal bicarbonate secretion, blood flow, cell turnover, prostaglandin production, and aggressive factors such as H. pylori infection, NSAID use, smoking, alcohol abuse, stress, and trauma. Such ulcers are common in the esophagus, stomach, and duodenum. Among all PUDs, 10-20% present complications such as perforation and gastric outlet obstruction, the most common being upper gastrointestinal bleeding. [3].
Kissing ulcers are a pair of ulcers present on opposite walls in the stomach or duodenum. [2]. Although commonly reported in the duodenum (1.5%) [1,2], stomach kissing ulcers are rarely reported in the literature. In our exhaustive search, we were only able to find four such case reports. [2,4-6]. Of these, two were due to trauma. [2,5]and the other was due to a percutaneous endoscopic gastrostomy tube [6]. The etiology was not mentioned in the fourth case; however, the use of an NSAID was ruled out [4].
The use of NSAID analgesics is associated with many gastrointestinal problems, leading to significant morbidity and even death. The prevalence of peptic ulcers in NSAID users is 14-25% and is usually more gastric than duodenal. However, up to 50% of endoscopically proven gastric ulcers are associated with NSAID analgesics. [7]. Also, taking NSAIDs in regular doses, even for a short time, increases the chance of having a PE. [3]. Other risk factors that may increase the severity of the impact of NSAIDs include advanced age (>70 years), previous history of ulcers, the first three months of treatment with NSAID analgesics, smoking, other cardiovascular comorbidities, H. pyloriand use of corticosteroids or anticoagulants [7].
Continuation of NSAID analgesics in a proven case of gastric ulcers delayed their healing. Therefore, the first step toward treatment is to discontinue the analgesic drug or reduce the dose if discontinuation is not feasible. However, if it is not possible to stop or reduce the dose of NSAID analgesics, the use of proton pump inhibitors or histamine type 2 receptor antagonists together with an NSAID may reduce the incidence of ulcers. [8]. The use of cyclooxygenase-2-specific NSAID analgesics is also recommended as an option. Surgical intervention is rarely required in acute presentations, such as intractable ulcer bleeding and perforation. [9].
Although it has been reported a few times in the duodenum, kissing ulcers are rarely reported in the stomach. Although the precise pathophysiology is still largely unknown, this unusual condition may be caused by sudden abdominal trauma or an episode of acute NSAID ingestion. The cessation of the use of NSAID analgesics and the addition of proton pump inhibitors leads to complete cure.