B.Kenan, et al. Surg Chron 2014; 19(2): 106-107. 106 A new trap in resistance to ulcer treatment :drug accummulation in base of ulcer Buyukasik Kenan,Duzkoylu Yigit, Can Gunhan, Ari Aziz, Bektas Hasan Istanbul Training and Research Hospital,General Surgery Clinic Abstract Peptic ulcer defines focal defects of submucosal tissue that might be seen in stomach but more frequently in duodenum. Increased secretion of acid is the main reason of duodenal ulcers while decreased defensive mechanism lies under the formation of gastric ulcers. Nonsteroidal anti-inflammatory drugs (NSAID) and Helicobacter Pylori infection are the most important factors leading to peptic ulcer. In this study, we presented a case of a 74 year old female patient who was admitted by internal medicine clinic due to pneumonia and new onset resistance to an antihypertensive medication of amlodipine besylate (Norvasc R 5 mg ,Pfizer). Gastric ulcer and a bolus of pills; which were accumulated in the base of that ulcer, were detected during esophagogastroduodenoscopy that was performed for epigastric pain and anemia. This case was presented to demonstrate that; in patients with peptic ulcer who were also receiving oral medications due to other diseases, probability of adherence to ulcer base may cause failure of oral treatment. Keywords: peptic ulcer, resistance to treatment, antihypertensive drug Introduction Peptic ulcer defines a defect in stomach or duodenum that may be submucosal or penetrate to deeper layers. Peptic ulcers may be acute or chronic and are due to imbalance between defensive mechanisms and peptic acid secretion (1). It was shown that 10% of population will be affected by symptomatic ulcers during their lifetime (2). In this study, we presented a case of new onset resistance to treatment with an antihypertensive medication (with an active ingredient of amlodipine besylate ) caused by accumulation of the drug in the base of the ulcer. We aimed to emphasize the probability of adherence of oral medication to base of the ulcer and its effects on treatment. Case report. Seventy-four year old female patient had admitted to the hospital with complaints of headache, palpitation, coughing, sputum and abdominal pain. In physical examination, there found to be coarsening in respiratory sounds, blood pressure (BP) was 190/100 mmHg and heart rate: 86/min. Chest X-Ray had revealed bilateral infiltrations. Laboratory findings were within normal limits other than WBC ( 17.500/ mm 3 ) and Hb (9.6 mg/dL). The patient had been hospitalized by internal medicine clinic with the diagnoses of hypertension and pneumonia. Patient’s history had revealed regular use of amlodipine besylate 1x1tablet for chronic hypertension ( Norvasc R 5 mg ) and irregular use of diclofenac sodium 100 mg tablet for arthralgia. Amlodipine besylate dosage had been increased to 2x1 peroral but hypertension had persisted. Third generation Cephalosporin had been started via iv route for pneumonia. Esophagogastroduodenoscopy was scheduled due to epigastric pain, regurgitation and anemia which the patient had been complaining during inpatient treatment. Esophagogastroduodenoscopy and colonoscopy were performed in the 5th day of admittance. Colonoscopy was within normal limits. Upper GI endoscopy findings; many pills had been adhered to base of ulcerative lesion of 1.5 x 2 cm size with depressed center and raised borders (Figure 1).The pills were removed away. The previously adhered pills were found to be of amlodipine besilate used as antihypertensive treatment. Biopsy was obtained from the lesion. Internal medicine specialists that had been following-up the patient were informed in case of an intoxication due to drug overdose. Figure 1. Endoscopic image of the ulcer with pills The patient’s pneumonia resolved while she was under treatment at internal medicine clinic for penumonia, hypertension and ulcer and blood pressure was regulated while complaints related to peptic ulcer had been relieved. She was discharged on the 14th day of admittance.