Bizarre gastric ulcer related to betel quid use: report of two cases

A 47-year-old gentleman, who had chewed 20 betel quids daily for 25 years, presented with a 3-day history of melena. Esophagogastroduodenoscopy (EGD) disclosed an ulcerated tumor 3 cm in size in the antrum ([Fig. 1]). Biopsy of the tumor revealed acute and chronic inflammation. The patient quit chewing betel quids. Because of a strong suspicion of malignancy, EGD was repeated 5 days later. It showed ulcers, from 0.5 to 2 cm in diameter, in the antrum. Biopsy again disclosed acute and chronic inflammation. Hence, betel-quid-related gastric injury was suspected. EGD 1 month later showed only a scar in the antrum ([Fig. 2]) and the histology again proved benign.

Fig. 1 Esophagogastroduodenoscopy (EGD) showed an ulcerated tumor 3 cm in size in the gastric antrum, involving the pyloric ring.

Fig. 2 EGD disclosed a small ulcer scar in the posterior wall of the gastric antrum.

Another 44-year-old gentleman, who had chewed 20 betel quids daily for 20 years, presented having produced coffee-ground vomitus for 1 day. EGD showed ulcers from 0.2 to 3 cm in diameter in the antrum ([Fig. 3]). Biopsy showed acute and chronic inflammation. Helicobacter pylori was found. Endoscopic ultrasound revealed thickening of the antrum. The mucosa and submucosa planes were blurred, but the muscularis propria was intact ([Fig. 4]). The patient quit chewing betel quids and underwent Helicobacter pylori eradication therapy. EGD 2 months later revealed two tiny healing ulcers in the antrum ([Fig. 5]). Biopsy disclosed chronic inflammatory cells in the lamina propria. EGD 3 months later showed only erythematous changes of the antral mucosa ([Fig. 6]).

Fig. 3 EGD showed scattered shallow ulcers measuring from 0.2 to 3 cm in diameter in the gastric antrum.

Fig. 4 Endoscopic ultrasound showed thickening of gastric antral wall, up to 10 mm in thickness.

Fig. 5 EGD disclosed two tiny healing ulcers in the gastric antrum.

Fig. 6 EGD disclosed mildly erythematous changes of the mucosa in the gastric antrum.

Betel quid consumption results in gastric ulcers in animal studies [1] [2]; this is the first report of betel-quid-induced ulcer in human patients. There is no laboratory marker, endoscopic finding, or pathologic feature pathognomonic of betel-quid-induced ulcer. Image studies aid little in the diagnosis. In areas where betel quid chewing is endemic, patients with gastric ulcer or suspected cancer should be asked whether they have a habit of betel quid use. These two cases show that betel-quid-related gastric ulcer can be bizarre in appearance and repeated biopsy is mandatory.

Endoscopy_UCTN_Code_CCL_1AB_2AD_3AC

References

• 1 Hung C R. Protective effects of lysozyme chloride and reduced glutathione on betel quid chewing-produced gastric oxidative stress and haemorrhagic ulcer in rats.  Inflammopharmacology. 2004;  12 115-129
• 2 Hung C R, Wang P S. Role of histamine and acid back-diffusion in modulation of gastric microvascular permeability and haemorrhagic ulcers in betel-quid-fed rats.  Inflammopharmacology. 2004;  12 277-287