Indian J. Pathol. Microbial.

37: 4; 389-393: 1994

>biol. October 1994

Fungal Colonization in Gastric Ulcers
RP Rex IH et al:
e cream 1 % in the RAMA RAMAN!, ANANTHAKRISHNAN RAMAN!*, GIRIJA R KUMAR!
cruris and tinea SANJIV A RAO*, SHILAJ CHKRA VARTHY** & PG SHIVAN ANDA
rmatol 2: 441-442, Departments of Microbiology, Pathology**, and Medicine*,
Kasturba Medical College, Manipal.
Jwell NR, Forster
t of dermatophyte
1ger and toe-nails
F 86-327, Lamisil),
1gicidal agent. Br J ABSTRACT
'58, 1989.
Until now studies on fungal colonization of gastric ulcers were
1d Artis WM: retrospective involving small series of patients. This prospective
Jtibility testing of study of 50 patients with gastirc ulcers (25 benign and 25 malignant)
nicrocultures with
gmented mycelial
revealed colonization by Candida in 17 (34%) cases. There was no
timicrob Agents significant difference in colonization between benign and malignant
29, 1980. ulcers. Follow up revealed no difference in healing of ulcers with
or without fungal colonization.

al, Key Words : Candida, Gastric ulcers, Benign, Malignant.

2/3/93 INTRODUCTION (25 benign and 25 malignant ulcers) for

Though oral candidiasis (thrush) is
a common form of fungal disease,
involvement of stomach is a very rare
event. 1 However, in the last few years
fungal colonization of gastric ulcers has
been reported in literature with
increasing frequency 234 Studies on
occurrence of fungi in gastric ulcers
have been retrospective involving small
or large sereis of patients24.s. Moreover,
it is not clearly established whether
fungal colonization is associated with
delayed healing, malignant lesions or
hypochlorhydria. We prospectively
studied fifty patients with gastric ulcer
presence of fungi, their incidence in
benign and malignant lesions and
relationship to therapy and healing.
MATERIAL AND METHODS
We prospectively studied 50
patients (aged 24-75 years) with gastric
ulcers. Histopathologically proven
benign and malignant ulcer case were
included in the study. For fungal
detection, the gastric biopsies w ere
taken from ulcer base as well as from
ulcer margins. Smears were prepared
from biopsy tissue and s tained by
Gram's method of staining. Tissue was
390 Ramani et al. Indian J. Pathol. Microbiol. October 1994 Indian J. Pathol.

cultured on Sabouraud's dextrose agar males. There appears to be no

slants. Identification and species significant difference in prevalence of
differentiation of the isolated fungi was fungi between benign gastric.ulcers and
done by standard methods 1 malignant ulcers. Fig. 2 and 3 shows
the fungi in benign and malignant
OBS ERVA TIO NS ulcers respectively.

Out of the 50 cases only 17 (34%) DISCUSSION

were positive for fungus. Smear
examination showed fungus only in 11 The prevalence of fungi in gastric
(22%) cases. Candida was the oruy genus ulcers varies widely. Older studies
detected in these ulcers. Out of 17 based on autopsy material reported a
Candida species, 15 were C. alibicans, prevalence of 4% while recent reports
remaining 2 belong to C. tropicalis. Fig. indicate prevalence varying form 5%
1 shows the age distribution. ulcers to 36% i,M. In the present study we
with fungi tended to be present in found 17 (34%) of 50 patients to have
patients of middle-age group. Table 1 fung_us. Prevalence was higher in
shows the sex distribution of patients middie aged patients (69.74%). There
with ulcers, with and without fungi. was no significant difference in the
Ulcers with fungi appeared to occur prevalence of fungi in benign (32%) and
eqully in males and females, though malignant (36%) gastric ulcers. Almost Fig. 2: Phot
overall, ulcers were more common .!_n all our patients in whom fungus was x 50

AGE DISTRIBUTION

9 Ulcers without Funyus Ulcers with Fungus

8 - - 8 8
,..---

7 - - 7

6
6 -
5
5
4 4
4 -
3
3-
2
,...._ 2
2 -
I .
1-

~ I I
~

10 20 30 40 50 60 70 80 90 0 10 20 30 40 50 60 70 80

YEARS - - - - -1- --
Fi,_g. 3: Photor
Fig. 1: Age distribution in cohorts for ulcers with and without fungus. x 500)
oiol. October 1994 Indian J. Pathol. Microbiol. October 1994 Fungal Colanization 391

~ars to be no
in prevalence of
~astric .ulcers and
. 2 and 3 shows
and malignant

f fungi in gastric
r. Older studies
1terial reported a
ile recent reports
rarying form 5%
'resent study we
patients to have
was higher in
' (69.74%). There
:iifference in the
benign (32%) and
Fig. 2: Photomicrograph of benign ulcer showing hyphae of Candida (PAS ,
ric ulcers. Almost
x 500).
horn fungus was

I .

60 70 so
Fig. 3: Photomicrograph of malignant ulcer showing hyphae of Candida (PAS,
ut fungus. x 500). -
392 Ramani et al. Indian J. Pathol. Microbial. October 1994 Indian J. Pathol. i

TABLE 1 ulcers in <

Gastroenterol
Fungal colonization in benign and malignant ulcers in males and females
4. Peters M, WE
Male Female Total Fungal infe
gastroduoden
and patho
With fungus 6 3 9 Gastroenterolo
Benign
ulcers 5. Loffeld RJLF.
Without fungus 11 5 16 JW, Flendrio
(25) JP: Fungal c<
ulcers. Am JG
With fungus 6 2 8 1988.
Malignant
ulcers
Without fungus Reprint Reque~
(25) 15 2 17

Total 38 12 50 Receivec

isolated were on Hz receptor antagonist
and our observation confirms earlier
reports.6 Nichols and Henry6 attributed
the role of Hz receptor blocking drugs
in facilitating growth of fungi by raising
the gastric pH. Secondary involvment
of the stomach by Candida following
vagotomy has been reported with
increasing frequency. 7 In a recent study8
invasive candidiasis, was seen in 2 of
20 (10%) duodenal ulcer patients before
treatment and in 6 of 20 (30%) patients
on cimetidine therapy. Therefore it
appears that fungal colonization of
gastric ulcers is more likely related to
the rise of gastric pH than disseminated
malignancy. Loffold et al 5 found
significantly slower healing initially in
gastric ulcers with fungi but ultimately
healing occurred within the same
period of time as the normal. Our
follow up results of both groups show
that all ulcers heal or show tendency
to heal within the same period of time.
In conclusion we feel that the
presence of fungi in gastric ulcers is
due to colonization and has little clinical
significance. The use of antimycotic
therapy, to improve the healing is
probably not justified.
REFERENCES
1. Rippon JW: Medical Mycology. The
pathogenic Fungi and the Pathogenic
Actinomycetes. Second edition, WB
Saunders Company, Philadelphia. 682-
698, 1982.
2. Antioniote A, Codluppi PL and Rigo
GP.: fungal infection of benign gastric
ulcer : clinical and endoscopic features.
Ital J Gastroenterol 16: 297-299, 1984.
3. Neoman A, Avdor I and Kodish U:
Candida infection of benign gastric
L October 1994 Indian J. Pathol. Microbial. October 1994 Fungal Colanization 393

ulcers in aged patients. Am J 6. Nichols PE and He_n ry K. : Gastritis

Gastroenterol 75: 211-213, 1981
ind females
4. Peters M, Weimer J and Whelom G.:
Fungal infection associated with
Total gastroduodenal ulceration: Endoscopic
and pathological appearances.
9 Gastroenterology 78: 350-354, 1980
and cimetidine : A possible
explanation. Lancet 2: 1095-1096, 1978.
7. Brooks JR, Smith HF and Pease FB :
Bacterology of the stomach
immediately following vagotomy .
Ann. Surg. 179: 859-862, 1974.

5. Loffeld RJLF, Loffeld BCAJ, Arends 8. Singh S, Singh N, Kochhar R, Talwar

16 JW, Aendrio JA and Van spresuwel P and Mehta SK. : Cimetidine therapy
JP: Fungal colonization in Gastric - and duodenal candidasis : Role in
ulcers. Am f Gastroenterol: 83: 730-733, healing process. Ind f Gastroenterol 11:
8 1988. 21-22, 1992.

Reprint Request: Dr. P.G. Shivananda, Professor Department of Microbiology,

17 Kasturba Medical College Manipal

50 Received - 23/7 /92 Modified - 28/10/92 Accepted - 31/12/92

period of time.

feel that the

1stric ulcers is
las little clinical
Jf antimycotic
:he healing is

Mycology . The
i the Pathogenic
nd edition, WB
'hiladelphia. 682-

ppi PL and Rigo

of benign gastric
loscopic features.
1: 297-299, 1984.

[ and Kodish U:
f benign gastric