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Cytomegalovirus Gastric Ulcer Complicated with Pyloric Obstruction in a Patient with Ulcerative Colitis

In patients with inflammatory bowel disease (IBD), cytomegalovirus (CMV) infections could aggravate the course of IBD but it is difficult to distinguish CMV infection from IBD exacerbation endoscopically. Usually, CMV tends to localize to the colon and other organic involvements were reported very rare in the IBD patients. Herein, we report a case that CMV gastric ulcer complicated with pyloric obstruction in a patient with ulcerative colitis during ganciclovir therapy, which was resolved by surgical gastrojejunostomy with review of literature. (Korean J Gastroenterol 2017;69:359-362)

2 It has been reported that the involvement of CMV infection simultaneously in the stomach and colon is extremely rare in UC.
Therefore, we report, with literature review, a case in which CMV gastric ulcer was complicated into complete gastric outlet obstruction in the middle of antiviral therapy in a patient with ulcerative colitis, which was superinfected by CMV infection.

CASE REPORT
A 36-year-old female patient was admitted presenting watery diarrhea and epigastric pain. Diarrhea developed remotely 6 months ago, which exacerbated 10 days prior to ad-   cumferentially was found, with a positive result of rapid urease test. The margin of ulcer was relatively clear, and the base was covered with exudates. Erythematous and friable mucosa with partially multiple mucosal defects were discovered across the entire colon, according to a colonoscopy for the evaluation of diarreha (Fig. 1). She was diagnosed endoscopically as active ulcerative colitis, accompanied by gastric ulcer. We started with steroid pulse therapy (intravenous methy-prednisolone 20 mg daily) for ulcerative colitis and proton pump inhibitor for gastric ulcer. In spite of steroid and proton pump inhibitor treatment, her symptoms did not improve. On the 8th day, according to her pathologic report, crypt abscess and inflammatory cell infiltration were found in the colonic mucosa, consistent with ulcerative colitis, and eosinophilic intranuclear inclusion body with acute inflammatory change was also noted, implying CMV infection (Fig. 2). To manage CMW infection, anti-viral agent, such as ganciclovir, was started and steroid treatment was tapered out. After the treatment using antiviral agent, her symptoms were greatly improved; however, on the 10th day of anti-viral therapy (the 44th day from admission), she complained of continuous vomiting. In a follow-up upper endoscopy, a large amount of fluid collections and pyloric stricture with healing ulcer were seen in the stomach, and as a result, the scope was not able to pass through. In the upper gastrointestinal series on the 45th day since admission, the dye did not pass through the pylorus, suggesting a complete pyloric obstruction (Fig. 3).
Consequently, endoscopic balloon dilatation was attempted, but failed, and surgical gastrojejunostomy was performed on the 47th day post-hospitalization. After the operation, vomiting was relieved. Then, she was discharged and she did not relapse during the follow-up period. In IBD patients, CMV infections could aggravate the course of IBD. The incidence of CMV infections in IBD patients receiving immunosuppressive therapy has been reported to be between 15.8 and 34%. 6 Moreover, it is difficult to endoscopically distinguish CMV infections from IBD exacerbation. to 8 percent of patients with gastric outlet obstruction. 8 Mostly gastric ulcer disease is associated with duodenal or pyloric channel ulceration. In our case, gastric ulcer was located on the pyloric channel and antrum, circumferentially and the patient was a high risk group for gastric outlet obstruction.

DISCUSSION
Therefore, to prevent gastric outlet obstruction, it would be better to place a temporary stent in the pylorus before starting any anti-viral and anti-ulcer medications. 9 In our case, temporary stent insertion was not possible due to complete obstruction.
In conclusion, it is important to suspect the possibility of CMV infection in IBD patients who were unresponsive to immunosuppressant drugs with other accompanying symptoms or signs that might suggest the involvement of other organs.