A bleeding gastric ulcer caused by anisakiasis.

A man in his 70s presented to the emergency unit for hematemesis. His recent blood test showed normal liver and renal function, and serum anti-Helicobacter pylori (H. pylori)IgG antibody was negative. He took neither steroids nor non-steroidal anti-inflammatory drugs (NSAIDs). Emergency endoscopy revealed a bleeding gastric ulcer in the greater curvature of the gastric body (Fig. 1A). Endoscopic hemostasis was performed using a combination of hemoclips and soft coagulation using hot biopsy forceps. Next day, second-look endoscopy revealed an Anisakis larva (Fig. 1B) on the edge of the ulcer. The larva was removed with biopsy forceps (Fig. 1C). He said that he ate pickled mackerel fish 5 days before hematemesis.

Figure 1

(A)Emergency endoscopy revealed a bleeding gastric ulcer in the greater curvature of the gastric body. (B) Second-look endoscopy revealed an Anisakis larva on the edge of the ulcer. (C) Histological examination showed the whole longitudinal body of an Anisakis larva

Anisakiasis is a human parasitic disease caused by eating undercooked or raw fish such as cod, salmon, herring or mackerel infected with third-stage Anisakis larvae [1,2]. Endoscopic appearance includes erythema, erosions, ulcerations, and submucosal tumor-like mass [2]. However, the incidence of bleeding gastric ulcers is low at 0.5% [3]. As Japanese dishes become popular around the world, consumption of raw fish food, sushi or sashimi, is increasing. We should be aware that anisakiasis can be a cause of non-H. pylori and non-NSAID peptic ulcer and bleeding.